The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes?

Clinical outcomes, medical costs, and medication usage patterns of different somatic symptom disorders and functional somatic syndromes: a population-based study in Taiwan

BACKGROUND

Somatic symptom disorders (SSD) and functional somatic syndromes (FSS) are often regarded as similar diagnostic constructs; however, whether they exhibit similar clinical outcomes, medical costs, and medication usage patterns has not been examined in nationwide data. Therefore, this study focused on analyzing SSD and four types of FSS (fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, functional dyspepsia).

METHODS

This population-based matched cohort study utilized Taiwan's National Health Insurance (NHI) claims database to investigate the impact of SSD/FSS. The study included 2 615 477 newly diagnosed patients with SSD/FSS and matched comparisons from the NHI beneficiary registry. Healthcare utilization, mortality, medical expenditure, and medication usage were assessed as outcome measures. Statistical analysis involved Cox regression models for hazard ratios, generalized linear models for comparing differences, and adjustment for covariates.

RESULTS

All SSD/FSS showed significantly higher adjusted hazard ratios for psychiatric hospitalization and all-cause hospitalization compared to the control group. All SSD/FSS exhibited significantly higher adjusted hazard ratios for suicide, and SSD was particularly high. All-cause mortality was significantly higher in all SSD/FSS. Medical costs were significantly higher for all SSD/FSS compared to controls. The usage duration of all psychiatric medications and analgesics was significantly higher in SSD/FSS compared to the control group.

CONCLUSION

All SSD/FSS shared similar clinical outcomes and medical costs. The high hazard ratio for suicide in SSD deserves clinical attention.

Alexithymia in Patients with Somatization Difficulties and Tinnitus-Related Distress: A Systematic Review

Chronic tinnitus, the perception of sound without an external source, can significantly affect individuals' well-being. As an often medically unexplained symptom, chronic tinnitus can present as a "somatoform" or "functional" difficulty. Some evidence has pointed to alexithymia as a transdiagnostically relevant risk factor for both symptom clusters. Using a two-part rapid review-searching within EBSCO, Embase by Ovid, PubMed, Web of Science-we summarize psychological studies regarding alexithymia, i.e., difficulties in recognizing and expressing emotions and (1) somatoform conditions and (2) chronic tinnitus. For the former (inclusion criteria: (1) adult human beings with different kinds of somatization, (2) longitudinal study designs, (3) publication between 2001 and 2021, (4) full-text in English or German) we identified eight studies that revealed significant links between alexithymia and somatoform conditions. Psychotherapy improved alexithymia in most studies. Additionally, alexithymia was associated with broader treatment outcomes such as improvements in pain intensity, gastrointestinal symptoms, and patient-therapist alliance. The 'Risk Of Bias In Non-randomized Studies-of Interventions' tool (ROBINS-I) and 'Revised Cochrane risk-of-bias tool for randomized trials' (RoB 2) were used for risk of bias assessment. Summarizing all available studies on alexithymia and chronic tinnitus, we identified three studies. Inclusion criteria were: (1) adult human beings with chronic tinnitus, (2) publication between 2001 and 2021, (3) full-text in English or German. Risk of bias was assessed by the 'JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies'. The available studies suggested a high rate of alexithymia (65.7%) in patients with chronic tinnitus. Tinnitus-related distress was significantly associated with alexithymia in two studies, one of which, however, found no differences in alexithymia between patients with bothersome versus non-bothersome tinnitus. Conversely, one study reported high levels of alexithymia in patients with low levels of tinnitus-related distress. Overall, alexithymia may be a transdiagnostic psychological indicator of somatization phenomena, which might include some chronic tinnitus presentations. Psychotherapy likely improves alexithymia as well as somatoform symptom presentations.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Population-based prevalence of somatic symptom disorder and comorbid depression and anxiety in Taiwan

OBJECTIVE

The nationwide prevalence of somatic symptom disorder (SSD) has not yet been investigated in Asia. SSD is often comorbid with depression and anxiety, and the effects of these conditions on medical utilization await clarification. We hence performed a study in Taiwan to explore these issues.

METHODS

Using telephone-based sampling and interview, we obtained data for 3161 participants whose age, gender and living area were compatible with the Taiwan population. We gathered scores of the Patient Health Questionnaire-15 (PHQ-15), Health Anxiety Questionnaire (HAQ) and Patient Health Questionnaire-4 (PHQ-4). Individuals with a PHQ-15 score of at least 4 and a HAQ score of at least 17 were considered to have SSD. Descriptive statistics were used to clarify the prevalence and normative data of the questionnaires. We used multiple logistic regression analyses to investigate the relation between diagnoses and medical utilization.

RESULTS

The prevalence of SSD was 5.00% and women had a higher SSD prevalence than men; participants aged 40-49 years had the highest SSD prevalence. In SSD patients, 33.58% had depression or anxiety. After correcting for demographics, SSD and anxiety (but not depression) were associated with a significantly high level of outpatient/emergency department attendance. Comorbid depression or anxiety did not significantly increase the medical utilization of SSD patients.

CONCLUSION

The nationwide SSD prevalence in Taiwan is compatible with the description in the DSM-5. The comorbidity of SSD and depression/anxiety is common, but depression or anxiety does not significantly increase the SSD patients' medical utilization.

Use of machine learning to diagnose somatic symptom disorder: Are the biomarkers beneficial for the diagnosis?

OBJECTIVES

We used machine learning to incorporate three types of biomarkers (respiratory sinus arrhythmia, RSA; skin conductance, SC; finger temperature, FT) for examining the performance of diagnosing somatic symptom disorder (SSD).

METHODS

We recruited 97 SSD subjects and 96 controls without psychiatric history or somatic distress. The values of RSA, SC and FT were recorded in three situations (resting state, under a cognitive task and under paced breathing) and compared for the two populations. We used machine learning to combine the biological signals and then applied receiver operating characteristic curve analysis to examine the performance of diagnosing SSD regarding the distinct indicators and situations. Subgroup analysis for subjects without depression/anxiety was also conducted.

RESULTS

FT was significantly different between SSD patients and controls, especially in the resting state and under paced breathing. However, the biomarkers (0.75-0.76) did not reveal an area under the curve (AUC) comparable with the psychological questionnaires (0.86). Combining the biological and psychological indicators gave a high AUC (0.86-0.92). When excluding individuals with depression/anxiety, combining three biomarkers (0.79-0.83) and adopting psychological questionnaires (0.78) revealed a similar AUC.

CONCLUSIONS

The performance of RSA/SC/FT was unsatisfactory for diagnosing SSD but became comparable when excluding comorbid depression/anxiety.

Multidisciplinary approach to functional somatic syndromes: study protocol for a population-based prospective cohort study

INTRODUCTION

Isfahan functional disorders (ISFUN) cohort study aims to describe the interplay of genetic and environmental factors in shaping the characteristics of functional somatic syndromes (FSS). This study is primarily intended to investigate the epidemiology, risk factors, course and prognosis of FSSs in a sample of adult Iranian population. The other aim is to develop a new delimitation of FSSs based on an integrated multidisciplinary approach comprising of phenotypic and multiomics data.

METHODS AND ANALYSIS

ISFUN is a population-based prospective cohort study designed to follow a population of randomly selected seemingly healthy adults (18-65 years) through annual visits during a 4-year observation period. Structured questionnaires are used for data collection and clinical assessment of the participants. Questionnaire-based diagnosis of FSSs are validated in a medical interview. Human DNA genotyping, microbial amplicon sequencing and urine analysis is under progress for genomics, microbiota and metabolomics profiling, respectively. Enrolment began in September 2017, and study completion is expected in 2022. A total number of 1943 participants were initially recruited.

ETHICS AND DISSEMINATION

Ethical approval for data collection was granted by the National Research Ethics Committee of the Iranian Ministry of Health and Medical Education and the Research Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1395.1.149). Following the description of the study procedure, we obtained written informed consent from all study participants. Study findings will be disseminated through peer-reviewed publications and presentations at scientific meetings.

A Longitudinal Study on Attenuated Structural Covariance in Patients With Somatic Symptom Disorder

OBJECTIVE

This study was performed to investigate altered regional gray matter volume (rGMV) and structural covariance related to somatic symptom disorder (SSD) and longitudinal changes after treatment. Additionally, this study examined the relationships of structural alteration with its phenotypic subtypes.

METHODS

Forty-three unmedicated patients with SSD and thirty normal controls completed psychological questionnaires and neurocognitive tests, as well as brain magnetic resonance imaging. Voxel-based morphometry and structural covariances were compared between groups and between subgroups within the SSD group. After 6 months of treatment, SSD patients were followed up for assessments.

RESULTS

Patients with SSD exhibited attenuated structural covariances in the pallidal-cerebellar circuit (FDR < 0.05-0.1), as well as regions in the default mode and sensorimotor network (FDR < 0.2), compared to normal controls. The cerebellar rGMVs were negatively correlated with the severity of somatic symptoms. In subgroup analyses, patients with somatic pain showed denser structural covariances between the bilateral superior temporal pole and left angular gyrus, the left middle temporal pole and left angular gyrus, and the left amygdala and right inferior orbitofrontal gyrus, while patients with headache and dizziness had greater structural covariance between the right inferior temporal gyrus and right cerebellum (FDR < 0.1-0.2). After 6 months of treatment, patients showed improved symptoms, however there was no significant structural alteration.

CONCLUSION

The findings suggest that attenuated structural covariance may link to dysfunctional brain network and vulnerability to SSD; they also suggested that specific brain regions and networks may contribute to different subtypes of SSD.

Association between Stroop tasks and heart rate variability features in patients with somatic symptom disorder

OBJECTIVE

Patients with somatic symptom disorder (SSD) may have declined parasympathetic activity and selective attention to negative information. We combined Stroop tasks and heart rate variability (HRV) measurements to explore the brain mechanism of SSD.

METHODS

104 SSD patients (64 women) and 100 healthy adults (76 women) received three Stroop tasks (the "cognitive" color-word Stroop, "emotional" emotion Stroop, and "cognitive and emotional" face-word Stroop) with low and high interference conditions. The key HRV indexes included high-frequency power (HF) and standard deviation of normal to normal RR intervals (SDNN). The generalized estimating equation model was used to examine the effects of SSD on three Stroop tasks performance (accuracy and reaction time) and HRV (HF and SDNN) controlling for sex, age, body mass index, and the levels of anxiety and depression.

RESULTS

For Stroop tasks, the significant group difference in emotion Stroop task with the high level of interference (SSD patients had lower accuracy than healthy ones) was only found in women. As for HRV, only men during color-word Stroop, women during emotion Stroop revealed significant between-group differences; SDNN in SSD men was higher than healthy men, and HF in SSD women was lower than healthy women controlling for the confounding factors. The significantly longer reaction time in SSD women than in healthy women diminished in the adjusted analysis.

CONCLUSION

Emotion Stroop task and HRV helps distinguish SSD patients from healthy adults, particularly in women. Sex-specific measures for early detection and intervention for SSD are suggested.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

DRKS00018803.

Evolution of bodily distress disorders

PURPOSE OF REVIEW

The nomenclature and classification of somatoform disorders have undergone revisions in the fifth edition of the Diagnostic and Statistical Manual (DSM 5) and the upcoming eleventh edition of the International Classification of Diseases (ICD-11). The present review describes the changes that have evolved and highlight the possible challenges.

RECENT FINDINGS

Bodily distress disorders replace the term somatoform disorders. The emphasis on the symptoms to be medically unexplained has been removed. The need to have a certain number of symptoms associated with different organ systems has made way to the presence of one or more distressing bodily symptoms. The focus on psychological aspects like excessive attention, thoughts, and behaviors associated with bodily symptoms have been added to make it a more diagnosis of inclusion rather than exclusion. An additional qualifier of severity has been added, which highlights the importance of impairment associated with these symptoms.

SUMMARY

The diagnostic criteria for bodily distress disorders is a step towards making the diagnostic criteria clinically useful and appears to be applicable across the healthcare settings. However, the ability to discern this diagnosis with the newly revised classification of chronic pain and the possibility of over psychologizing the medical disorders need to be researched.

Functional somatic disorders: discussion paper for a new common classification for research and clinical use

BACKGROUND

Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs.

MAIN BODY

We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrum - and also within organ system-specific chapters of a classification - they should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD).

CONCLUSION

We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.

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

Prevalence of functional somatic syndromes (FSS) in the general population varies with observed overlap between syndromes. However, studies including a range of FSS are sparse. We investigated prevalence and characteristics of various FSS and the unifying diagnostic construct bodily distress syndrome (BDS), and identified mutual overlap of the FSS and their overlap with BDS. We included a stratified subsample of 1590 adults from a randomly selected Danish general population sample (n = 7493). Telephonic diagnostic interviews performed by three trained physicians were used to identify individuals with FSS and BDS. Prevalence of overall FSS was 9.3%; 3.8% for irritable bowel, 2.2% for chronic widespread pain, 6.1% for chronic fatigue, 1.5% for whiplash associated disorders, and 0.9% for multiple chemical sensitivity. Prevalence of BDS was 10.7% where 2.0% had the multi-organ type. FSS were highly overlapping with low likelihood of having a “pure” type. Diagnostic agreement of FSS and BDS was 92.0%. Multi-syndromatic FSS and multi-organ BDS were associated with female sex, poor health, physical limitations, and comorbidity. FSS are highly prevalent and overlapping, and multi-syndromatic cases are most affected. BDS captured the majority of FSS and may improve clinical management, making the distinction between multi- and mono-syndromatic patients easier.

The unifying diagnostic construct of bodily distress syndrome (BDS) was confirmed in the general population

OBJECTIVES

Bodily distress syndrome (BDS) has been shown to encompass a range of functional somatic syndromes (FSS) such as irritable bowel syndrome (IBS), fibromyalgia (FM), and chronic fatigue syndrome (CFS) in clinical samples. This study aimed to explore symptom clusters and test classification of individuals with illness similar to the BDS criteria in a general population sample.

METHODS

A stratified subsample of 1590 individuals from the DanFunD part two cohort was included. Symptoms were assessed with the Research Interview for Functional somatic Disorders, performed by trained physicians. In 44 symptoms pooled from criteria of IBS, FM, CFS, and BDS, symptom clusters were explored with explorative factor analysis. Confirmation of symptom clusters of BDS in the previously described 25- and 30-item BDS checklists was performed with confirmatory factor analysis. Classification of individuals into illness groups was investigated with latent class analysis.

RESULTS

Four symptom clusters (cardiopulmonary, gastrointestinal, musculoskeletal, general symptoms/fatigue) corresponding to the BDS subtypes and their corresponding FSS were identified and confirmed. A three-class model including 25 BDS items had the best fit for dividing participants into classes of illness: One class with low probability, one class with medium probability, and one class with high probability of having ≥4 symptoms in all symptom clusters.

CONCLUSION

The BDS concept was confirmed in the general population and constitutes a promising approach for improved FSS classification. It is highly clinical relevant being the only diagnostic construct defining the complex multi-organ type.

General practitioners' views on the diagnostic innovations in DSM-5 somatic symptom disorder - A focus group study

BACKGROUND

The innovations concerning the new diagnosis somatic symptom disorder (SSD) in the DSM-5 include the introduction of psychological diagnostic criteria and the elimination of the need to exclude all potential somatic causes of the symptoms. Thus far, it is unknown how general practitioners (GPs) evaluate the innovations conceptually and regarding their applicability in primary care.

METHOD

We performed six focus groups with GPs. A semi-structured interview-guideline included a presentation of the innovations of SSD and questions about the innovations and their potential (dis-)advantages from the GPs' points of view. The material was analyzed using structuring qualitative content analysis.

RESULTS

A total of 41 GPs participated (mean (sd) age = 51 (8.5) years, female = 17, male = 24). The GPs assessed that the diagnostic innovations could help them to focus on symptom-related concerns and anxiety as core aspects of the patients' complaints. However, the meaning of the term excessive in the psychological diagnostic criteria (i.e., excessive worries, anxiety, time and energy) was ambiguous for the GPs. The GPs appreciated that a mental disorder can be assigned in addition to a severe physical disease. The GPs found it unlikely that diagnostic workup of somatic symptoms would be cut short if the diagnostic criteria of SSD were fulfilled in a given patient.

CONCLUSION

Altogether, for the GPs, the advantages of the new diagnostic criteria for SSD outweighed the disadvantages. In particular, the newly included psychological criteria were seen as an important advancement in comparison to the previous need of merely excluding a physical disease.

Autonomic reactivity during reading of a somatic distress script in patients with somatic symptom disorder

OBJECTIVE

The relationship between resting-state heart rate variability (HRV) and somatic symptom disorder (SSD) has been explored in several studies. We planned to examine HRV during the performance of psychological tasks, and assumed that it could be applied for the diagnosis of SSD.

METHODS

Fifty-three patients with SSD and 52 healthy controls were recruited. Demographic and psychological data were collected. Subjects' HRV was measured over five 5-minute blocks during which they viewed different scripts (resting state; health anxiety; somatic distress; depression; neutral topic). After each block they completed a self-assessment manikin. Generalized estimated equation analysis was used to analyze the impact of mental scripts, SSD and sex on physiological and psychological indicators.

RESULTS

In men there was a script*SSD interaction concerning high-frequency power (HF) involving the neutral script; SSD men showed significantly higher HF than healthy men when viewing neutral script. In women there were script*SSD interactions with respect to low-frequency power (LF) and HF involving the somatic distress script and a script*SSD interaction with respect to LF and emotional valence involving the neutral script; SSD women revealed significantly lower LF and HF than healthy women when viewing somatic distress script, they also showed significantly lower LF and higher valence than healthy ones during neutral script. The somatic distress script*SSD interaction still influenced LF and HF in women after adjusting for potential confounders.

CONCLUSION

In women cue-specific HRV is a better method of differentiating people with SSD from healthy individuals than resting-state HRV.

TRIAL REGISTRATION INFORMATION

The Research Ethics Committee of National Taiwan University Hospital approved this study (approval number: 201410050RINB).

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders

BACKGROUND

DSM-5 introduced a fundamental revision of the category of somatoform disorders, which resulted in the new somatic symptom disorder (SSD) and related disorders. However, prognostic validity of SSD remains unclear, while other classification proposals, such as bodily distress disorder (BDD) or polysymptomatic distress disorder (PSDD), might be promising alternatives for the new ICD-11. Therefore, the comparison of the different approaches concerning long-term prognosis of disorder-relevant factors is of special interest.

METHOD

In a longitudinal design (baseline, 1-year, and 4-year follow-up), the three proposals (SSD, BDD, PSDD) were compared in an age-representative sample of the German general population (N = 321). To this end, the baseline sample was divided into three independent pairs of groups (with/without SSD, with/without BDD, with/without PSDD). It was tested how well each approach differentiated with regard to medium- and long-term healthcare utilization, number of symptoms, and impairment.

RESULTS

Criteria for BDD distinguished best with regard to future healthcare utilization resulting in a large-sized effect (f = 0.44) for the difference between persons with and without BDD, while SSD and PSDD revealed only medium-sized effects (f = 0.28 and f = 0.32) between subjects with and without diagnosis. The three proposals distinguished equally well with regard to future subjective impairment (between f = 0.39 and f = 0.41) and the number of reported symptoms (between f = 0.77 and f = 0.83).

CONCLUSION

In accordance with our data regarding prognostic validity, the current draft of the WHO group is based on the BDD proposal. However, existing limitations and weaknesses of the present proposal for the ICD-11 are further discussed.

Juvenile Fibromyalgia: A Primary Pain, or Pain Processing, Disorder

Juvenile fibromyalgia (JFM), a chronic disorder of widespread musculoskeletal pain in combination with autonomic, sensory, and cognitive dysfunction, is responsible for considerable morbidity and impaired quality of life in affected patients and their families. Historically, fibromyalgia has been incorrectly characterized as a psychosomatic or psychogenic disorder, but new understanding of the science of pain has demonstrated unambiguously that it is an organic disorder of the pain processing system itself. This new science provides a framework for understanding the pathophysiology of fibromyalgia and for developing rational therapeutic interventions. Advances in JFM include the verification of adult criteria for diagnosis in pediatric patients and the publication of effective therapies based on cognitive and physical neuromuscular intervention. Although primarily nonpharmacologic therapy can include adjunctive medications as well. Finally, the recognition that JFM is a disorder of the central and peripheral nervous systems suggests that neurologists can be important in the care of these patients.

Neural correlates of somatoform disorders from a meta-analytic perspective on neuroimaging studies

Somatoform disorders (SD) are common medical disorders with prevalence rates between 3.5% and 18.4%, depending on country and medical setting. SD as outlined in the ICD-10 exhibits various biological, social, and psychological pathogenic factors. Little is known about the neural correlates of SD. The aims of this meta-analysis are to identify neuronal areas that are involved in SD and consistently differ between patients and healthy controls. We conducted a systematic literature research on neuroimaging studies of SD. Ten out of 686 studies fulfilled the inclusion criteria and were analyzed using activation likelihood estimation. Five neuronal areas differ between patients with SD and healthy controls namely the premotor and supplementary motor cortexes, the middle frontal gyrus, the anterior cingulate cortex, the insula, and the posterior cingulate cortex. These areas seem to have a particular importance for the occurrence of SD. Out of the ten studies two did not contribute to any of the clusters. Our results seem to largely overlap with the circuit network model of somatosensory amplification for SD. It is conceivable that functional disorders, independent of the clinical impression, show similar neurobiological processes. While overlaps do occur it is necessary to understand single functional somatic syndromes and their aetiology for future research, terminology, and treatment guidelines.

•

Five neurobiological areas correlate with the occurrence of somatoform disorders (SD).

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Areas are crucial for emotional, evaluative and cognitive aspects of pain processing.

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Prefrontal areas indicate involvement of pain memory in SD.

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Functional disorders might have central sensitization as an underlying factor.

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Results do not support the classification of SD as medically unexplained symptoms.

Bodily distress syndrome: A new diagnosis for functional disorders in primary care?

Background

Conceptualisation and classification of functional disorders appear highly inconsistent in the health-care system, particularly in primary care. Numerous terms and overlapping diagnostic criteria are prevalent of which many are considered stigmatising by general practitioners and patients. The lack of a clear concept challenges the general practitioner’s decision-making when a diagnosis or a treatment approach must be selected for a patient with a functional disorder. This calls for improvements of the diagnostic categories. Intense debate has risen in connection with the release of the fifth version of the ‘Diagnostic and Statistical Manual of Mental Disorders’ and the current revision of the ‘International Statistical Classification of Diseases and Related Health Problems’. We aim to discuss a new evidence based diagnostic proposal, bodily distress syndrome, which holds the potential to change our current approach to functional disorders in primary care. A special focus will be directed towards the validity and utility criteria recommended for diagnostic categorisation.

Discussion

A growing body of evidence suggests that the numerous diagnoses for functional disorders listed in the current classifications belong to one family of closely related disorders. We name the underlying phenomenon ‘bodily distress’; it manifests as patterns of multiple and disturbing bodily sensations. Bodily distress syndrome is a diagnostic category with specific criteria covering this illness phenomenon. The category has been explored through empirical studies, which in combination provide a sound basis for determining a symptom profile, the diagnostic stability and the boundaries of the condition. However, as bodily distress syndrome embraces only the most common symptom patterns, patients with few but impairing symptoms are not captured. Furthermore, the current lack of treatment options may also influence the acceptance of the proposed diagnosis.

Summary

Bodily distress syndrome is a diagnostic category with notable validity according to empirical studies. Nevertheless, knowledge is sparse on the utility in primary care. Future intervention studies should investigate the translation of bodily distress syndrome into clinical practice. A particular focus should be directed towards the acceptability among general practitioners and patients. Most importantly, it should be investigated whether the new category may provide the basis for better treatment and improved clinical outcome.

Perspectives on the clinical significance of functional pain syndromes in children

Functional pain syndromes (FPS) characterize a subset of individuals who experience pain and related symptoms and disability without clear structural or disease etiology. In the pediatric population, FPS hold high clinical importance due to significant prevalence rates and potential to persist into adulthood. Although extensive research has been executed to disambiguate FPS, the syndromes that fall within its spectrum remain conceptually complex and sometimes ill-defined. This paper provides an overview of available research on the classification and multifaceted etiology of FPS in youth and their effects on interpersonal, psychological, and familial function. Vital aspects of a successful multidisciplinary approach to treating this population are described; however, it is evident that future research requires more longitudinal studies.

Somatic symptoms and psychological concerns in a general adolescent population: Exploring the relevance of DSM-5 somatic symptom disorder

OBJECTIVE

DSM-5 somatic symptom disorder (SSD) constitutes a major change for psychosomatic medicine and psychiatry, as well as for epidemiological research in these fields. This study investigates somatic symptoms and psychological concerns among adolescents in order to systematically explore the relevance of SSD for general adolescent populations.

METHODS

A cross-sectional population-based design, with a symptoms-based strategy and a symptom-and-psychological-concern-based strategy, was used to estimate the prevalence of somatic symptoms and psychological concerns in a general adolescent population (n=2476, mean age=16years, 49% boys, 51% girls). Somatic symptoms and psychological concerns in relation to gender, and self-reported medical and psychiatric conditions were investigated. The association between somatic symptoms, psychological concerns, and functional impairment in school-, family-, peer- and physical activities was studied.

RESULTS

Reporting 3+ persistent distressing somatic symptoms was significantly more common than reporting one or more persistent distressing somatic symptom(s) combined with serious psychological concern. The prevalence of such complaints was significantly higher in girls. The proportion of medical and psychiatric conditions was highest in the group reporting 3+ persistent distressing somatic symptoms combined with serious psychological concern. Belonging to this group most significantly increased odds ratios for functional impairment.

CONCLUSION

For large-scale studies on SSD, results suggest the use of measures based on multiple somatic items in combination with psychological concerns, and a methodologically sound standardized measure of functional impairment. To further enhance clinical decision-making, the relation of symptoms to functional impairment, and the substantial overlap of SSD with medical and psychiatric conditions during adolescence should be addressed.

The Self beyond Somatic Symptoms: A Narrative Approach to Self-Experience in Adolescent Chronic Fatigue Syndrome

BACKGROUND

The self and self-experience are often assumed to play an important role in adolescent patients presenting with severe somatic symptoms and bodily distress. Nonetheless, most empirical work on this subject is confined to studies of personality and patients' experience of negative emotionality. This study aims to move beyond mere descriptions of symptoms, traits and distress, and consequently adopts a narrative approach to self-experience in adolescent chronic fatigue syndrome (CFS).

SAMPLING AND METHODS

The self-confrontation method (SCM) is a well-validated instrument to systematically analyze narrative self-experience. The SCM was used to study 42 adolescents with CFS, compared to 36 adolescents with juvenile idiopathic arthritis (JIA) and 25 matched healthy controls. The Child Health Questionnaire (CHQ-CF87) was used to assess mental health, self-esteem, and physical and psychosocial functioning.

RESULTS

Both patient groups reported significantly less positive self-experience of autonomy and success compared to healthy controls. Furthermore, patients with CFS described significantly more negative self-experience of powerlessness, isolation and unfulfilled longing. In the CHQ-CF87, both patient groups scored significantly lower on physical functioning than controls. Adolescents with CFS also scored significantly lower on mental health and self-esteem.

CONCLUSIONS

Adolescent CFS entails a serious threat to the self, which might be inherent to the condition. Not only are patients more impaired in mental health, self-esteem, and physical and psychosocial functioning than patients with JIA, they also suffer from a distinct combination of high negative and low positive self-experience. These findings stress the need for strategies that empower patients towards a 'management of the self'.