Are somatoform disorders 'mental disorders'? A contribution to the current debate

Mental illness rates among employees with fixed-term versus permanent employment contracts: a Danish cohort study

PURPOSE

It has been hypothesized that employment in a fixed-term instead of permanent contract position is associated with an increased risk of development of mental health problems. The present study aimed at estimating rate ratios between fixed-term and permanent employees in the Danish labor force, for use of psychotropic drugs and psychiatric hospital treatment due to mood, anxiety or stress-related disorders, respectively.

METHODS

Employment data were drawn from the Danish Labor Force Survey of 2001-2013, which is a part of the European Labor Force Survey. Full-time employed survey participants without mental illness at the baseline interview (N = 106,501) were followed in national health registers for up to 5 years. Poisson regressions were used to estimate rate ratios for redeemed prescriptions of psychotropic drugs and psychiatric hospital treatments due to mood, anxiety or stress-related disease. The analyses were controlled for age, gender, industrial sector, nighttime work, level of education, calendar year, disposable family income and social transfer payments within 1 year prior to the baseline interview.

RESULTS

The rate ratio for hospital diagnosed mood, anxiety or stress-related disorders among employees with fixed-term vs. permanent employment contracts was estimated at 1.39 (99.5% CI 1.04-1.86), while the corresponding rate ratio for redeemed prescriptions of psychotropic drugs was estimated at 1.12 (99.5% CI 1.01-1.24).

CONCLUSION

The present study supports the hypothesis that employment in a fixed-term rather than permanent contract position is associated with an increased risk of developing mental health problems.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR2-10.2196/24392.

Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders

Somatic symptoms which are not fully explained by a medical condition (medically unexplained symptoms) have a high relevance for the public health. They are very common both in the general population and in patients in health care, and may develop into chronic impairing conditions such as somatoform disorders. In recent years, the relevance of specific negative psychological factors for the diagnosis and the stability of somatoform disorders and for the impairment by medically unexplained symptoms gained more and more attention. This resulted-among others- in core changes in the diagnostic classification criteria of somatoform disorders. Against this background, the present "Perspective" will outline recent developments and findings in the area of medically unexplained somatic symptoms and somatoform disorders. Moreover, it will lay a special focus on evidence on specific negative psychological factors that may influence the course of unexplained somatic symptoms and disorders and the impairment caused by these symptoms.

Interoceptive accuracy and bias in somatic symptom disorder, illness anxiety disorder, and functional syndromes: A systematic review and meta-analysis

Somatic symptom disorder, illness anxiety disorder, and functional syndromes are characterized by burdensome preoccupation with somatic symptoms. Etiological models propose either increased interoceptive accuracy through hypervigilance to the body, or decreased and biased interoception through top-down predictions about sensory events. This systematic review and meta-analysis summarizes findings of 68 studies examining interoceptive accuracy and 8 studies examining response biases in clinical or non-clinical groups. Analyses yielded a medium population effect size for decreased interoceptive accuracy in functional syndromes, but no observable effect in somatic symptom disorder and illness anxiety disorder. The overall effect size was highly heterogeneous. Regarding response bias, there was a small significant effect in somatic symptom disorder and illness anxiety disorder. Our findings strengthen the notion of top-down factors that result in biased rather than accurate perception of body signals in somatic symptom disorder and illness anxiety disorder.

The Association of Sensory Responsiveness with Somatic Symptoms and Illness Anxiety

BACKGROUND

Somatoform Disorders or Somatic Symptom and Related Disorders are a major public health problem.The pathophysiology underlying these disorders is not yet understood.

PURPOSE

The aim of this study was to explore if sensory responsiveness could contribute to a better understanding of pathophysiological mechanisms underlying two key symptoms of Somatoform Disorders, namely somatic symptoms and illness anxiety.

METHODS

We measured vibrotactile perception thresholds with the HVLab Perception Meter and examined their association with somatic symptoms, illness anxiety and trait anxiety. A sample of 205 volunteers participated in the study.

RESULTS

Sensory responsiveness was neither associated with somatic symptoms (β = -0.01; 95% confidence interval (CI), -0.37, 0.39) nor trait anxiety (β = -0.07; 95% CI, -0.30, 0.07). However, lower vibrotactile perception thresholds were associated with increased scores of the overall illness anxiety scale (β = -0.65; 95% CI, -1.21, -0.14) and its constituent subscale disease conviction (β = -2.07; 95% CI, -3.94, -0.43).

CONCLUSIONS

Our results suggest that increased sensory responsiveness is associated with illness anxiety and hence should be examined further as potential target within the etiopathology of somatoform disorders.

Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS)

OBJECTIVE

This study aimed (1) to describe frequencies of DSM IV somatisation disorder, undifferentiated somatoform disorder and pain disorder versus DSM 5 somatic symptom disorder (SSD) in a multi-setting population of patients with medically unexplained physical symptoms (MUPS), (2) to investigate differences in sociodemographic and (psycho)pathological characteristics between these diagnostic groups and (3) to explore the clinical relevance of the distinction between mild and moderate DSM 5 SSD.

METHODS

We used baseline data of a cohort of 325 MUPS patients. Measurements included questionnaires about symptom severity, physical functioning, anxiety, depression, health anxiety and illness perceptions. These questionnaires were used as proxy measures for operationalization of DSM IV and DSM 5 diagnostic criteria.

RESULTS

92.9% of participants fulfilled criteria of a DSM IV somatoform disorder, while 45.5% fulfilled criteria of DSM 5 SSD. Participants fulfilling criteria of DSM 5 SSD suffered from more severe symptoms than those only fulfilling criteria of a DSM IV somatoform disorder(mean PHQ-15 score of 13.98 (SD 5.17) versus 11.23 (SD 4.71), P-value<0.001). Furthermore their level of physical functioning was significantly lower. Compared to patients with mild SSD, patients with moderate SSD suffered from significantly lower physical functioning and higher levels of depression.

CONCLUSION

Within a population of MUPS patients DSM 5 SSD criteria are more restrictive than DSM IV criteria for somatoform disorders. They are associated with higher symptom severity and lower physical functioning. However, further specification of the positive psychological criteria of DSM 5 SSD may improve utility in research and practice.

Do the various categories of somatoform disorders differ from each other in symptom profile and psychological correlates

BACKGROUND

In routine clinical practice, the subcategories of various somatoform disorders are rarely used by the primary care physicians and there is lack of data to suggest any difference in the clinical manifestations of these subcategories.

AIM

To compare the symptom profile, anxiety, depression, alexithymia, somato-sensory amplification and hypochondriasis of patients with persistent somatoform pain disorder with other subtypes of somatoform disorder.

METHOD

A total of 119 patients diagnosed with somatoform disorders according to the International Classification of Diseases-10th Revision (ICD-10) were evaluated for prevalence of somatic symptoms, anxiety, depression, alexithymia, hypochondriacal worry and somato-sensory amplification.

RESULTS

No significant differences were found in the prevalence of various somatic complaints between those with persistent somatoform pain disorder group and those diagnosed with other somatoform disorders. Co-morbid anxiety and depression were seen in two-thirds of the patients, but again there was no difference in the prevalence of the same between the two groups. Similarly, no significant differences were found on alexithymia, hypochondriasis and somato-sensory amplification scales between the persistent somatoform pain disorder group and the group with other somatoform disorders.

CONCLUSION

There are no significant differences between the various subcategories of somatoform disorders with regard to the prevalence of somatic symptoms, anxiety or depression and psychological correlates of alexithymia, hypochondriasis and somato-sensory amplification.

The influence of mindfulness on upper extremity illness

BACKGROUND

Previous studies suggest a benefit of mindfulness-based interventions on pain conditions. This study addresses the null hypothesis that mindfulness is not correlated with pain intensity or magnitude of disability in orthopedic upper extremity conditions.

METHODS

In a prospective cohort, the correlation of the two separate aspects of mindfulness-acceptance and awareness-with disability and pain intensity was tested in patients with nonacute upper extremity conditions. Regression analyses were performed to determine factors associated with arm-specific disability and pain intensity.

RESULTS

Awareness and acceptance both correlated with arm-specific disability, but only awareness was retained as a predictor in the best multivariable model. Neither awareness nor acceptance correlated with pain intensity. Pain interference and symptoms of depression accounted for more of the variation in disability and pain intensity.

CONCLUSION

Improved mood and decreased pain interference (a greater sense that one can accomplish one's goals in spite of pain) may be more fruitful than increased mindfulness for patients with nonacute conditions of the upper extremity.

Multiple somatic symptoms predict impaired health status in functional somatic syndromes

BACKGROUND

The relationship between functional somatic syndromes and multiple somatic symptoms is unclear.

PURPOSE

We assessed whether the number of somatic symptoms is a predictor of health status in three functional somatic syndromes (FSS).

METHODS

In a population-based study of 990 UK adults we assessed chronic widespread pain (CWP), chronic fatigue (CF) and irritable bowel syndrome (IBS) by questionnaire and medical record data. We assessed health status (Short Form 12 and EQ-5D), number of somatic symptoms (Somatic Symptom Inventory) and anxiety/depression (Hospital Anxiety and Depression Scale) both at baseline and at follow-up 1 year later.

RESULTS

The proportion of people with an FSS who also have multiple somatic symptoms (52-55 %) was similar in the three functional syndromes. The presence of multiple somatic symptoms was associated with more impaired health status both at baseline and at follow-up. This finding was not explained by severity of FSS. In the absence of multiple somatic symptoms, the health status of the FSS was fair or good. In multiple regression analysis, the number of somatic symptoms, the presence of a functional syndrome (CWP or CF) and anxiety/depression were predictors of EQ-5D thermometer at follow-up after adjustment for confounders.

CONCLUSIONS

Multiple somatic symptoms in people with an FSS are associated with impaired health status and this cannot be explained by more severe functional syndrome or the presence of anxiety and depression.

Somatic symptom and related disorders in Asians and Asian Americans

Somatic manifestation is common in the Asian population. The frequent occurrence of somatic symptom and related disorders among Asians could well be explained by an overt emphasis on 'somatic' idioms of distress on the one hand, and unacceptability and stigma attached to psychological expression of distress on the other. Assessment and diagnosis of somatoform disorders is complicated by the scarcity of cross-culturally validated instruments. Likewise, management is also based on Western literature in which psychological interventions override pharmacological treatment. DSM-5 has broadened the scope of somatoform disorders and emphasizes the concept rather than simply counting symptoms. These changes are expected to have a positive impact cross-culturally.

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder: prospective 1-year follow-up study

OBJECTIVE

To compare the predictive validity and clinical utility of DSM-IV somatoform disorders and DSM-5 Somatic Symptom Disorder (SSD) at 12-month follow-up.

METHODS

In a sample of psychosomatic inpatients (n=322, mean age=45.6 years (SD 10.0), 60.6% females) we prospectively investigated DSM-IV somatoform disorders and the DSM-5 diagnosis of SSD plus a variety of psychological characteristics, somatic symptom severity, and health-related quality of life at admission, discharge, and follow-up.

RESULTS

DSM-IV diagnoses and DSM-5 SSD similarly predicted physical functioning at follow-up; SSD also predicted mental functioning at follow-up. Bodily weakness, intolerance of bodily complaints, health habits, and somatic attribution at admission were significant predictors of physical functioning at follow-up. The change in physical functioning during inpatient therapy was a significant predictor for the course of physical functioning until follow-up.

CONCLUSIONS

Psychological symptoms appear to be predictively valid diagnostic criteria for the 12-month functional outcome in patients with SSD. Mental functioning can be better predicted by the DSM-5 diagnosis than by DSM-IV diagnoses. Not the change in single psychological features but in physical functioning during the treatment interval predicted the change in physical functioning until follow-up.

Potentially harmful side-effects: medically unexplained symptoms, somatization, and the insufficient illness narrative for viewers of mystery diagnosis

Illness narrative has often been found to play a positive role in both patients' and providers' efforts to find meaning in the illness experience. However, illness narrative can sometimes become counterproductive, even pathological, particularly in cases of medical mystery--cases wherein biopsychosocial factors blur the distinction between bodily dysfunction and somatizing behavior. In this article, the author draws attention to two examples of medical mystery, the clinical presentation of medically unexplained symptoms, and the popular reality television program Mystery Diagnosis, to demonstrate the potentially harmful effects of illness narrative. The medical mystery's complex narrative structure reflects and tends to reinforce providers' and patients' mistaken assumptions, anxieties, and conflicts in ways which obstruct, rather than facilitate, healing.

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.

Behavioural and psychological management of somatic symptom disorders: an overview

The number of patients who seek help at primary and secondary care for somatic symptoms which cannot be explained by any known medical condition is enormous. It has been proposed to rename 'somatoform disorders' in DSM-IV as 'somatic symptom disorders' in DSM-5. This is supposed to include disorders such as somatization disorder, hypochondriasis, undifferentiated somatoform disorder, pain disorder and factitious disorder. The reason for the renaming and grouping is that all these disorders involve presentation of physical symptoms and/or concern about medical illness. In the literature, there is considerable variation adopted with respect to diagnosis and in the approaches adopted for intervention. However, the common feature of these disorders is the chronicity, social dysfunction, occupational difficulties and the increased healthcare use and high level of dissatisfaction for both the clinician and the patient. A number of behavioural and psychological interventions for somatic symptoms have been carried out at primary, secondary and tertiary care settings and recently there have been more attempts to involve the primary care physicians in the psychological interventions. This review aims at giving an overview of the components of the behavioural and other psychological interventions available for addressing medically unexplained somatic symptoms and to present their efficacy.

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder--comparison with DSM-IV somatoform disorders and additional criteria for consideration

OBJECTIVE

Major changes to the diagnostic category of somatoform disorders are being proposed for DSM-5. The effect of e.g. the inclusion of psychological criteria (criterion B) on prevalence, predictive validity, and clinical utility of "Somatic Symptom Disorder" (SSD) remains unclear. A prospective study was conducted to compare current and new diagnostic approaches.

METHODS

In a sample of N=456 psychosomatic inpatients (61% female, mean age=44.8±10.4 years) diagnosed with somatoform, depressive and anxiety disorders, we investigated the current DSM-5 proposal (SSD) plus potential psychological criteria, somatic symptom severity, and health-related quality of life at admission and discharge.

RESULTS

N=259 patients were diagnosed with DSM-IV somatoform disorder (56.8%). With a threshold of 6 on the Whiteley Index to assess psychological criteria, the diagnosis of SSD was similarly frequent (51.8%, N=230). However, SSD was a more frequent diagnosis when we employed the recommended threshold of one subcriterion of criterion B. Patients diagnosed with only SSD but not with DSM-IV somatoform disorder showed greater psychological impairment. Both diagnoses similarly predicted physical functioning at discharge. Bodily weakness and somatic and psychological attributions at admission were among significant predictors of physical functioning at discharge. Reduction of health anxiety, bodily weakness, and body scanning significantly predicted an improvement of physical functioning.

CONCLUSIONS

Psychological symptoms enhance predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder compared to DSM-IV somatoform disorders. The SSD diagnosis identifies more psychologically impaired patients than its DSM-IV precursor. The currently suggested diagnostic threshold for criterion B might increase the disorder's prevalence.

The subject, its biology, and the chronic recurrent cystitis

Functional disorders in urology are troubling for both patients and physicians. Moreover, advances in recent research promise to provide biological insights into psycho-neuro-endocrino-immunological pathways that are one important facet of chronic urogenital inflammations. We present a case of a middle-aged woman with long-lasting recurrent cystitis for which especially a psychosomatic approach helped to understand and cure the disorder. Altogether, as practitioners treat subjects, not illnesses, a biopsychosocial understanding of human disease should be taken into account in cases of chronic recurrent cystitis.

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.

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.

Can neuroimaging help us to understand and classify somatoform disorders? A systematic and critical review

OBJECTIVE

Debate about the nature of somatoform disorders and their current diagnostic classification has been stimulated by the anticipation of new editions of Diagnostic and Statistical Manual of Mental Disorders and International Statistical Classification of Diseases and Related Health Problems diagnostic classifications. In the current paper, we review systematically the literature on the neuroimaging of somatoform disorders and related conditions with the aim of addressing two specific questions: Is there evidence of altered neural function or structure that is specifically associated with somatoform disorders? What conclusions can we draw from these findings about the etiology of somatoform disorders?

METHODS

Studies reporting neuroimaging findings in patients with a somatoform disorder or a functional somatic syndrome (such as fibromyalgia) were found using Pubmed, PsycINFO, and EMBASE database searches. Reported structural and functional neuroimaging findings were then extracted to form a narrative review.

RESULTS

A relatively mature literature on symptoms of pain and less developed literatures on conversion and fatigue symptoms were identified. The available evidence indicates that, when compared with nonclinical groups, somatoform diagnoses are associated with increased activity of limbic regions in response to painful stimuli and a generalized decrease in gray matter density; however, methodological considerations restrict the interpretation of these findings.

CONCLUSIONS

Whereas the neuroimaging literature has provided evidence about the possible mechanisms underlying somatoform disorders, this is not yet sufficient to provide a basis for classification. By adopting a wider variety of experimental designs and a more dynamic approach to diagnosis, there is every reason to be hopeful that neuroimaging data will play a significant role in future taxonomies.

Are psychological features useful in classifying patients with somatic symptoms?

OBJECTIVE

To evaluate psychological characteristics that could be used for the classification of somatic syndromes requesting medical care. Positive psychological classification criteria are needed to justify the classification of somatic syndromes as Diagnostic and Statistical Manual of Mental Disorders- or International Classification of Diseases-10 section F/mental disorders diagnosis.

METHODS

From a population-based sample of 2510 people, subsamples reporting high scores for somatic symptoms (SOM+; n = 154) versus average scores for somatic symptoms (SOM-; n = 167) were defined. Telephone interviews (e.g., structured interviews for diagnoses, healthcare use, symptom history, possible psychological characteristics), self-rating scales (e.g., Pain Disability Index, depression scale Patient Health Questionnaire-9), and general practitioners reports were collected for these subsamples. In addition to somatic symptoms, we used healthcare use and disability as major external validation criteria.

RESULTS

There was strong evidence for ten of the 28 binary coded psychological variables to identify those people with somatic symptoms who needed medical help and/or were seriously disabled. These variables included "avoidance of physical activities," "bias for somatic illness attributions," "self-concept of being physically weak," and "desperation because of somatic symptoms." The relevance of these psychological characteristics was partially further confirmed by stepwise regression analyses, which showed incremental validity compared with variables like somatic symptoms and depression.

CONCLUSIONS

This study identified several psychological characteristics of people with somatic complaints who need medical care. These features can be assessed, using binary variables that are more feasible for classification processes. These psychological criteria should be included in classification rules for people with somatic syndromes (e.g., somatoform disorders).

Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care

OBJECTIVE

(i) To analyze general practitioners' diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner.

METHODS

Cross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient.

RESULTS

Of the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented.

CONCLUSIONS

ICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.

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.

Commonalities and differences between the diagnostic groups: current somatoform disorders, anxiety and/or depression, and musculoskeletal disorders

OBJECTIVE

To identify the similarities and differences of risk factors and correlates of different groups of people fulfilling criteria for specified diagnostic groups according to current somatoform disorder (SDs) criteria, presence of anxiety and/or depression, and self-reported musculoskeletal disorders.

METHODS

Participants of the Oslo-Lofoten general population cross-sectional study in 2000-2001 interviewed with the Composite International Diagnostic Interview (CIDI) somatoform section were examined by comparing similarities and differences in 8 groups identified by cross-tabulation of current SDs, anxiety and/or depression, and musculoskeletal disorders. The current SDs group was computed from the CIDI somatoform section raw data, anxiety and/or depression from the CIDI diagnostic algorithms and musculoskeletal disorders by questionnaire and self evaluation.

RESULTS

In the 2001 sample of 1668 (875 women and 793 men) participants, the following eight disorder groups were identified: (i) current SDs, n=49 (75.5% women) (ii) musculoskeletal (functional somatic disorders), n=327; (53.5% women) (iii) anxiety and/or depression, n=148 (73.6% women); (iv) current SDs with anxiety and/or depression, n=38 (73.7% women); (v) current SDs with musculoskeletal, n=44 (72.7% women); (vi) current SDs with anxiety and/or depression and musculoskeletal, n=34 (76.5% women); (vii) musculoskeletal with anxiety and/or depression, n=101 (66.3% women); and (viii) no disorders, n=927 (43.3% women). Commonalities and differences between current SDs, anxiety and/or depression, and musculoskeletal disorders are apparent. Impairment of outcomes and risk factor load is high in current SDs with anxiety and/or depression and musculoskeletal.

CONCLUSION

The data in this article could help toward the needed DSM-V and ICD-11 diagnostic revision of the SDs category.

The role of comorbidity in the detection of psychiatric disorders with checklists for mental and physical symptoms in primary care

OBJECTIVE

To examine the contribution of a mental and physical symptom count to the detection of single or comorbid anxiety, depressive and somatoform disorders.

METHOD

In primary care 1,046 consulting patients completed the Hospital Anxiety and Depression Scale (HADS) and the Physical Symptom Checklist (PSC-51). In a stratified sample of 473 patients DSM-IV psychiatric disorders were assessed using the WHO-SCAN interview. The diagnostic value of the HADS total score and the PSC-51 symptom count was examined with ROC-analyses.

RESULTS

The discriminative power of PSC-51 and HADS was highest for patients with both a somatoform disorder and an anxiety or depressive disorder, with an AUC of 0.86 (95% CI: 0.81-0.91) and 0.91 (95% CI: 0.87-0.94) respectively. Using both symptom counts together did not increase the diagnostic value for the detection of the psychiatric disorders.

CONCLUSION

Both symptom counts preferentially detected patients with comorbid disorders. When interpreting diagnostic values of screening questionnaires one should keep in mind that the validity of these values can be dependent of the presence of comorbid disorders.

[Definition, classification and diagnosis of fibromyalgia syndrome]

BACKGROUND

Interdisciplinary guidelines for the definition, classification and diagnosis of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS) were developed by collaboration of 10 German medical and psychological associations and 2 patient self-help organizations.

METHODS

A systematic literature search was performed in the Cochrane Library (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/2006). Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. Grading of the strength of recommendation was done according to the German program for disease management guidelines. Standardized procedures to reach a consensus on recommendations were used.

RESULTS

CWP is defined by the criteria of the American College of Rheumatology (ACR--strong consensus). FMS can be diagnosed for clinical purposes by symptom-based criteria (without tender point examination) as well as by the ACR criteria (strong consensus).

Cognitive-affective neuroscience of somatization disorder and functional somatic syndromes: reconceptualizing the triad of depression-anxiety-somatic symptoms

Somatization disorder is a somatoform disorder that overlaps with a number of functional somatic syndromes and has high comorbidity with major depression and anxiety disorders. Proposals have been made for revising the category of somatoform disorders, for simplifying the criteria for somatization disorder, and for emphasizing the unitary nature of the functional somatic syndromes in future classifications. A review of the cognitive-affective neuroscience of somatization disorder and related conditions suggests that overlapping psychobiological mechanisms mediate depression, anxiety, and somatization symptoms. Particular genes and environments may contribute to determining whether symptoms are predominantly depressive, anxious, or somatic, and there are perhaps also overlaps and distinctions in the distal evolutionary mechanisms that produce these symptoms.

Redefining (somatoform) pain disorder in ICD-10: a compromise of different interest groups in Germany

PURPOSE OF REVIEW

Pain is one of the most frequent reasons to visit health professionals. Many patients suffering from chronic pain conditions not only need medical treatment but also psychiatric or psychological interventions. This additional treatment need should be underlined using an ICD section F diagnosis. The current ICD-10 diagnosis of somatoform pain disorder requests psychological causation of the pain, which is frequently unclear or difficult to decide.

RECENT FINDINGS

In Germany, the different interest groups, namely of psychiatry, pain research, psychosomatic medicine and clinical psychology, met to find a consensus on how to re-classify pain disorder under section F of ICD-10. This manuscript summarizes the result.

SUMMARY

A diagnosis of pain disorder is necessary to underline the additional need of psychiatric/psychological interventions in chronic pain conditions. This diagnosis should include psychological features that are relevant for development or maintenance of chronic pain. In contrast to earlier attempts of redefining pain diagnoses, our attempt included representatives of the association for the study of pain.

Recent developments in the understanding and management of functional somatic symptoms in primary care

PURPOSE OF REVIEW

Medically unexplained or functional somatic symptoms are prevalent in primary care, but general practitioners commonly find them difficult to treat. We focus on the conceptual issues and treatment from a primary care perspective, although the field is difficult to review because of the inconsistency and multiplicity of terminology used by different authors and specialties.

RECENT FINDINGS

The training of general practitioners in management techniques has been hampered by an obsolete theoretical framework and outdated diagnostic systems. Epidemiological studies, however, indicate that valid, empirically based diagnostic criteria for functional disorders may be developed. Management studies in primary care have shown disappointing effects on patient outcome, but a lot may be gained by making the training programmes more sophisticated. Recently, stepped care approaches have been introduced but they need scientific evaluation.

SUMMARY

There is an immediate need for a common language and a theoretical framework of understanding of functional symptoms and disorders across medical specialties, clinically and scientifically. Any names that presuppose a mind-body dualism (such as somatization, medically unexplained) ought to be abolished. The overall ambition for treatment is to offer patients with functional somatic symptoms the same quality of professional healthcare as we offer any other patient.

Update on consultation-liaison psychiatry (psychosomatic medicine)

PURPOSE OF REVIEW

Current issues in consultation-liaison psychiatry, which is now labeled psychosomatic medicine as a formal subspecialty by the American Board of Psychiatry and Neurology, are discussed.

RECENT FINDINGS

There is continued interest in how to best manage depression and anxiety in a primary-care setting. Collaborative care that utilizes a psychiatrist within the treatment center, as well as case management by a nurse, have been reviewed and meta-analyses suggest it is an efficient and effective approach. The diagnostic issues within psychosomatic medicine are also an area of concern as the Diagnostic and Statistical Manual of Mental Disorders, 5 edition, is in the planning stages. How to improve both the reliability and validity of somatoform disorders will be a major challenge. Organ transplantation is a clinical challenge for patients, donors and healthcare providers. Issues in assessment and management continue to evolve. Ethical questions also arise due to the shortage of available organs.

SUMMARY

Psychosomatic medicine continues to manage patients in medical settings that cut across a continuum from primary-care to complex medical and surgical centers. The clinical problems containing a medical-psychiatric interface offer a clinical challenge but also an area for new knowledge and better interventions.

Follow-up study on health care use of patients with somatoform, anxiety and depressive disorders in primary care

Background

Better management of affective and somatoform disorders may reduce consultation rates in primary care. Somatoform disorders are highly prevalent in primary care and co-morbidity with affective disorders is substantial, but it is as yet unclear which portion of the health care use may be ascribed to each disorder. Our objective was to investigate the use of primary care for undifferentiated somatoform disorders, other somatoform disorders, anxiety and depressive disorders prospectively.

Methods

In eight family practices 1046 consulting patients (25–79 yrs) were screened and a stratified sample of 473 was interviewed. Somatoform disorders, anxiety and depressive disorders were diagnosed (DSM IV) using SCAN 2.1. The electronic records of 400 participants regarding somatic diseases, medication and healthcare use were available through their family physicians (FP).

Results

In the follow-up year patients with psychiatric disorders had more face-to-face contacts with the FP than patients who had no psychiatric disorder: average 7–10 versus 5. The impact on the use of primary care by patients with somatoform disorders was comparable to patients with depressive or anxiety disorders. Undifferentiated somatoform disorders had an independent impact on the use of primary care after adjustment for anxiety and depressive disorders, resulting in 30% more consultations (IRR 1.3 (95% CI: 1.1–1.7)). Anxiety disorders had no independent effect.

Conclusion

Health care planning should focus on the recognition and treatment of somatoform as well as affective disorders.

Correlation of psychological and physical symptoms with chronically elevated cytokine levels associated with a common immune dysregulation

BACKGROUND

Chronically elevated levels of proinflammatory cytokines are associated with inflammatory diseases and psychological symptoms of depression and tiredness.

OBJECTIVE

To test the prediction that, in a healthy population without medically diagnosed diseases, psychological symptoms (depression and tiredness) associated with proinflammatory cytokines correlate with physical symptoms associated with inflammatory disease.

METHODS

A total of 1,143 women between 45 and 65 years old completed a health complaint checklist containing 11 target symptoms (5 related to allergy, 4 to gastrointestinal symptoms, and 2 to pain), 7 control symptoms or health complaints, and 2 psychological symptoms (depression and tiredness). They also completed a menopausal quality-of-life questionnaire; to compensate for response bias, we removed variance attributable to quality of life.

RESULTS

The partial correlations show that tiredness (but not depression) correlated with 9 of the 11 target symptoms (P < .001) but with 0 of the 7 control symptoms or complaints. Symptoms of both the specific and the systemic components of inflammatory disease are correlated in a healthy population.

CONCLUSION

Immune dysregulation may explain the existence and covariation of psychological and physical symptoms in the healthy population, including people with medically unexplained symptoms.

Stability of somatoform symptoms--implications for classification

OBJECTIVE

To investigate the stability of somatoform symptoms/disorders.

METHODS

A literature search was done to select studies reporting data on stability of medically unexplained physical symptoms.

RESULTS

Whereas individual symptoms vary over time, grouping symptoms into syndromes seems to create stable features. There are substantial problems with the use of lifetime diagnosis, favoring classification approaches that require only present state symptoms. Further, doctors' ratings that symptoms are "medically unexplained" is highly problematic and reduces interrater reliability. Misdiagnoses and overlooking of organic conditions are in the same range as for other psychiatric (and many organic) disorders; therefore, this does not seem to reduce the stability of the diagnoses of somatoform disorders.

CONCLUSIONS

These results indicate how the classification of somatoform disorders can be improved. Some new diagnostic criteria are suggested that could be considered in the revision of Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V).