Research priorities for medically not yet explained symptoms expressed by patients, carers, and healthcare professionals in the Netherlands following the James Lind Alliance priority setting partnership approach

OBJECTIVE

Experiencing physical symptoms that are medically not yet explained (MNYES) is associated with considerable burden in daily life. Research priorities in this area have been primarily investigator-driven. The present study identifies the top 10 research priorities, incorporating the views of patients, carers and healthcare professionals.

METHODS

This study used the Priority Setting Partnership approach in collaboration with the James Lind Alliance (JLA). The priority setting approach combines survey-based data from patients with a specific disorder/condition and relevant stakeholders (i.e., caregivers and healthcare professionals) with input from group meetings and a final priority setting consensus meeting. There were three consecutive phases: (1) online survey with an open-ended question to collect topics for future scientific research (N = 345 participants); (2) an online survey among stakeholders to prioritise the research questions generated in Phase 1 (N = 400); and (3) a final multi-stakeholder consensus meeting, held over two half-days to determine the final top 10 research priorities for the Netherlands (day 1 N = 25, day 2 N = 24).

RESULTS

Phase 1 resulted in 572 topics, which were reduced to 37 summary research questions. Phase 2 resulted in 18 research priorities, that were ranked and the top 10 priorities were established during the final consensus meeting. The top 10 research priorities included three main themes: optimising efficient diagnosis and treatment, aetiology and prevention, and coping with MNYES.

CONCLUSION

The top 10 priorities provide insight into what is most important for future research into MNYES from the perspective of patients, carers and healthcare professionals.

Neuropsychological features of somatic symptom disorder and depression/anxiety in Taiwan: An analysis based on the comorbidity status

Individuals with somatic symptom disorder (SSD) often have comorbid depression or anxiety, but whether SSD is associated with specific neuropsychological functions has yet to be fully examined. We analyzed which neuropsychological features are more closely associated with SSD, anxiety, and depression. In this case-control study, we recruited 140 individuals with SSD, 104 individuals with affective disorders without SSD, and 159 healthy controls in Taiwan. We collected DSM-5 diagnoses, questionnaire scores, and performance on eight tasks from the Cambridge Neuropsychological Test Automated Battery (CANTAB) for each participant. Several CANTAB tasks involving attention, executive function, and social cognition showed significant group differences. In the adjusted analysis, the tasks significantly associated with SSD were the Match to Sample Visual Search (MTS) and the Emotion Recognition Task (ERT). Among the questionnaires, the Cognitions about Body and Health Questionnaire showed the most significant associations with the tasks, specifically with Rapid Visual Information Processing, MTS, Paired Associates Learning, Spatial Working Memory, Intra-Extra Dimensional Set Shift, and ERT. We conclude that the MTS and ERT tasks show significant relationships with both SSD diagnosis and related questionnaires. These tasks primarily involve selective attention and negative emotion regulation.

Somatic symptom disorder symptoms in individuals at risk for heart failure: A cluster analysis with cross-sectional data from a population-based cohort study

OBJECTIVE

Identifying whether experienced symptom burden in individuals with medical predisposition indicates somatic symptom disorder (SSD) is challenging, given the high overlap in the phenomenology of symptoms within this group. This study aimed to enhance understanding SSD in individuals at risk for heart failure.

SUBJECTS AND METHODS

Cross-sectional data from the Hamburg City Health Study was analyzed including randomly selected individuals from the general population of Hamburg, Germany recruited from February 2016 to November 2018. SSD symptoms assessed with the Somatic Symptom Scale-8 and the Somatic Symptom Disorder-12 scale were categorized by applying cluster analysis including 412 individuals having at least 5% risk for heart failure-related hospitalization within the next ten years. Clusters were compared for biomedical and psychological factors using ANOVA and chi-square tests. Linear regressions, adjusting for sociodemographic, biomedical, and psychological factors, explored associations between clusters with general practitioner visits and quality of life.

RESULTS

Three clusters emerged: none (n = 215; 43% female), moderate (n = 151; 48% female), and severe (n = 46; 54% female) SSD symptom burden. The SSS-8 mean sum scores were 3.4 (SD = 2.7) for no, 6.4 (SD = 3.4) for moderate, and 12.4 (SD = 3.7) for severe SSD symptom burden. The SSD-12 mean sum scores were 3.1 (SD = 2.6) for no, 12.2 (SD = 4.2) for moderate, and 23.5 (SD = 6.7) for severe SSD symptom burden. Higher SSD symptom burden correlated with biomedical factors (having diabetes: p = .005 and dyspnea: p ≤ .001) and increased psychological burden (depression severity: p ≤ .001; anxiety severity: p ≤ .001), irrespective of heart failure risk (p = .202). Increased SSD symptoms were associated with more general practitioner visits (β = 0.172; p = .002) and decreased physical quality of life (β = -0.417; p ≤ .001).

CONCLUSION

Biomedical factors appear relevant in characterizing individuals at risk for heart failure, while psychological factors affect SSD symptom experience. Understanding SSD symptom diversity and addressing subgroup needs could prove beneficial.

Illness Anxiety Disorder: A Review of the Current Research and Future Directions

PURPOSE OF REVIEW

We review recent evidence on Illness Anxiety Disorder (IAD), including risk factors and precipitants, diagnostic classification, clinical characteristics of the disorder, and assessment and treatment in both children and adults.

RECENT FINDINGS

IAD places a substantial burden on both individuals and society. Despite its impact, understanding of the disorder is lacking and debates remain about whether IAD should be classified as an anxiety disorder and whether it is distinct from Somatic Symptom Disorder. Cognitive behavioural therapy (CBT) is an effective treatment for IAD and there are multiple validated measures of health anxiety available. However, research on health anxiety in children and youth is limited. IAD is chronic, and debilitating, but when identified, it can be effectively treated with CBT. Research using DSM-5 IAD criteria is lacking, and more research is needed to better understand the disorder, particularly in children and youth.

Psychological risk factors of somatic symptom disorder: A systematic review and meta-analysis of cross-sectional and longitudinal studies

OBJECTIVE

Current diagnostic concepts of somatic symptom disorder (SSD) in DSM-5 and bodily distress disorder (BDD) in ICD-11 require certain psychological criteria, but researchers have called for further specification. Therefore, in a first step, this systematic review and meta-analysis aimed to summarize the current evidence on psychological factors associated with SSD/BDD and/or disorder-relevant clinical outcomes such as symptom severity and impairment.

METHODS

Psychological factors were systematically searched using Pubmed, Cochrane Library and Psycinfo via EBSCO. Studies providing original data in English or German, after 2009 were included. Cross-sectional, cohort and case-control studies investigating at least one psychological factor in individuals with SSD/BDD in the context of disorder-relevant outcomes were included.

RESULTS

Forty-three eligible studies (n = 3760 patients) in SSD (none in BDD) provided data on at least one psychological factor, 37 in case-control format, 10 cross-sectional and 5 longitudinal. Meta-analyses of the case-control studies found patients with SSD to be more impaired by depression (SMD = 1.80), anxiety (SMD = 1.55), health anxiety (SMD = 1.31) and alexithymia (SMD = 1.39), compared to healthy controls. Longitudinal results are scarce, mixed, and require refining, individual studies suggest self-concept of bodily weakness, anxiety and depression to be predictive for persistent SSD and physical functioning.

CONCLUSION

This review provides a detailed overview of the current evidence of psychological factors in relation to SSD/BDD. Future studies on SSD and BDD should include under-studied psychological factors, such as negative affect, fear avoidance, or emotion regulation. More longitudinal studies are needed to assess the predictive value of these factors.

Psychological flexibility in somatic symptom and related disorders: A case control study

A key diagnostic criterion of Somatic Symptom and related Disorders (SSD) comprises significant distress and excessive time-and-energy consuming thoughts, feelings, and behavior pertaining to somatic symptoms. This diagnostic criterion is lacking in central sensitivity syndromes (CSS), such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome. This strong emphasis on disturbed psychological processing of somatic symptoms, suggests that psychological flexibility is low in SDD. Psychological flexibility is defined as the ability to approach difficult or challenging internal states (thoughts, emotions, and bodily sensations) in a non-judgmental, mindful way, and being committed to pursue one's values. To clarify the potential significance of psychological flexibility in SSD, we examined its levels in 154 people referred to specialized treatment for SDD, as compared to reference groups from the general population encompassing 597 people with CSS and 1422 people without SSD or CSS (controls). Mean levels of psychological flexibility (adjusted for demographic covariates) were lowest for SSD and highest for controls (F = 154.5, p < 0.001, pη2 = 0.13). Percentages of people with low psychological flexibility (<0.8 SD below the mean of controls) were: SSD 74%, CSS 42%, controls 21%. In SSD, higher psychological flexibility was associated with better mental health (β = 0.56, p < 0.001), but interaction analysis rejected that psychological flexibility preserved health when having more severe somatic symptoms (β ≤ 0.08, p ≥ 0.10). The results indicate that lower psychological flexibility is a prevalent problem in SSD that is associated with lower mental health. This suggests that it is worthwhile to take account of psychological flexibility in SSD in screening, monitoring, and therapy.

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.

Reliability and Validity of the Korean Version of the Somatic Symptom Disorder-B Criteria Scale in a Clinical Population

OBJECTIVE

This study aimed to develop and validate the Korean version of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in outpatients at a psychiatric clinic and assess its diagnostic accuracy.

METHODS

A total of 207 patients completed SSD-12. For the diagnostic accuracy of SSD-12, the somatic symptom disorder (SSD) section of the structured clinical interview for DSM-5 disorders-research version (SCID-5-RV) was used. The SSD-12 construct and concurrent validity were assessed by examining the correlations with Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), PHQ-15, 5-level EQ-5D version (EQ-5D-5L), and World Health Organization Quality of Life Brief Version (WHOQOL-BREF).

RESULTS

The SSD-12 had excellent internal consistency (Cronbach α=0.90). Confirmatory factor analysis revealed good fit indices for a general factor model (comparative fit index [CFI]=0.92, Tucker-Lewis index [TLI]=0.88, root mean square error of approximation [RMSEA]=0.10; 95% confidence interval [CI], 0.08-0.11) and a three-factor model (CFI=0.94, TLI=0.91, RMSEA=0.08; 95% CI, 0.07-0.10). The total SSD-12 score was significantly correlated with anxiety (GAD-7: r=0.53, p<0.001), depression (PHQ-9: r=0.52, p<0.001), physical symptom burden (PHQ-15: r=0.36, p<0.001), and quality of life (EQ-5D-5L: r=-0.40, p<0.001; WHOQOL-BREF: r=-0.51, p<0.001). SSD-12 demonstrated good accuracy (area under the curve=0.75, standard error=0.04; 95% CI, 0.68-0.82) with an optimal cut-off of 29.

CONCLUSION

The Korean SSD-12 demonstrates reliability and validity for diagnosing SSD in clinical setting.

Expanding the notion of mechanism to further understanding of biopsychosocial disorders? Depression and medically-unexplained pain as cases in point

Evidence-Based Medicine has little consideration for mechanisms and philosophers of science and medicine have recently made pleas to increase the place of mechanisms in the medical evidence hierarchy. However, in this debate the notions of mechanisms seem to be limited to 'mechanistic processes' and 'complex-systems mechanisms,' understood as 'componential causal systems'. I believe that this will not do full justice to how mechanisms are used in biological, psychological and social sciences and, consequently, in a more biopsychosocial approach to medicine. Here, I propose, following (Kuorikoski, 2009), to pay more attention to 'abstract forms of interaction' mechanisms. The present work scrutinized review articles on depression and medically unexplained pain, which are considered to be of multifactorial pathogenesis, for their use of mechanisms. In review articles on these disorders there seemed to be a range of uses between more 'abstract forms of interaction' and 'componential causal system' mechanisms. I therefore propose to expand the notions of mechanisms considered in medicine to include that of more 'abstract forms of interaction' to better explain and manage biopsychosocial disorders.

Subjective and physiological reactivity to emotional stressors in somatic symptom disorder

OBJECTIVE

We examined whether autonomic flexibility to experimentally presented stressors is reduced in somatic symptom disorder (SSD) as this would point to reduced vagal control as a proposed indicator of emotion regulation deficits.

METHOD

In this experimental study, the influence of health-related and social stressors on subjective and physiological reactivity was investigated in 29 subjects with SSD without any medical condition SSD(mc-), 33 subjects with SSD with medical condition SSD(mc+) and 32 healthy controls at the age from 18 to 70 years. Self-report and physiological variables were measured before and after/during stressor exposure, using state ratings of symptom intensity, disability, tension and mood, heart rate (HR), and heart rate variability (HRV).

RESULTS

Overall, the tension increased and the mood worsened after exposure to stressors compared to pre-exposure. Compared to HC, the two SSD groups showed higher symptom intensity, disability, tension and worse mood. The SSD(mc-) group revealed higher HR than HC (p = .012, d = -0.77). Compared to pre-exposure, symptom impairment increased after social stressor exposure in SSD(mc-) (p < .001, d = 1.36). HRV-root mean square of successive differences (RMSSD) only decreased in HC during exposure (p = .003, d = -1.09), not in the SSD groups. The two SSD groups did not differ in their reactivity to stressors.

CONCLUSION

HRV in SSD, seems to respond less flexibly to stressors, potentially reflecting overall physiological disturbance through reduced parasympathetic influence on HR. Stress reactivity in SSD(mc-) and SSD(mc+) do not seem to differ.

Inflammatory Bowel Disease and Irritable Bowel Syndrome: What Differences in Mentalization Abilities? A Scoping Review

Mentalization is a psychological process that enables individuals to understand the self and others in terms of intentional mental states. The aim of this scoping review was to provide an overview of the findings on mentalization in patients with inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). A literature search, in line with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols extension for Scoping Review guidelines, was conducted in the following bibliographic databases: PubMed, PsycINFO, and Scopus. Databases were queried using the following strings (with Boolean operators): ("mentaliz*" OR "metacogniti*" OR "theory of mind" OR "ToM" OR "reflective function*") AND ("irritable bowel syndrome" OR "IBS" OR "inflammatory bowel disease" OR "IBD"). In line with the eligibility criteria, seven articles were included. Results showed that no significant differences in metacognitive ability were found between patients in the IBD and IBS groups. This review revealed the mentalizing difficulties for patients with IBD and IBS. These results should be interpreted with caution since they are based on a few studies that used different instruments to assess mentalizing processes. Future studies are needed to clarify the role of mentalization in patients with these gastrointestinal conditions.

Psychological risk factors for Long COVID and their modification: study protocol of a three-arm, randomised controlled trial (SOMA.COV)

BACKGROUND

Growing evidence suggests that in addition to pathophysiological, there are psychological risk factors involved in the development of Long COVID. Illness-related anxiety and dysfunctional symptom expectations seem to contribute to symptom persistence.

AIMS

With regard to the development of effective therapies, our primary aim is to investigate whether symptoms of Long COVID can be improved by a targeted modification of illness-related anxiety and dysfunctional symptom expectations. Second, we aim to identify additional psychosocial risk factors that contribute to the persistence of Long COVID, and compare them with risk factors for symptom persistence in other clinical conditions.

METHOD

We will conduct an observer-blinded, three-arm, randomised controlled trial. A total of 258 patients with Long COVID will be randomised into three groups of equal size: targeted expectation management in addition to treatment as usual (TAU), non-specific supportive treatment plus TAU, or TAU only. Both active intervention groups will comprise three individual online video consultation sessions and a booster session after 3 months. The primary outcome is baseline to post-interventional change in overall somatic symptom severity.

CONCLUSIONS

The study will shed light onto the action mechanisms of a targeted expectation management intervention for Long COVID, which, if proven effective, can be used stand-alone or in the context of broader therapeutic approaches. Further, the study will enable a better understanding of symptom persistence in Long COVID by identifying additional psychological risk factors.

Respiratory Interoception and Pathological Illness Anxiety: Disentangling Bias

OBJECTIVE

Biased interoception decoupled from physiology might be relevant in the etiology of pathological illness anxiety (PIA). Empirical evidence for interoceptive deviations in illness anxiety is scarce but potentially informative to optimize treatments. We hypothesized that persons with PIA differ fundamentally in the classification of bodily sensations from those without PIA.

METHODS

In a respiratory categorization task, participants breathed into a pulmonary training device. Inspiration effort was varied by eight resistive loads. The lower/higher four loads were introduced as belonging to arbitrary categories "A"/"B," respectively. Participants memorized respiratory sensations in a first experimental block and were asked to label the resistances in a second block. We calculated the sensitivity of resistance classification according to category and response bias in terms of categorical misclassification. Data of 39 participants with PIA and 35 controls were compared with regard to sensitivity and response bias by group, resistive load, and their interaction in a multiple regression.

RESULTS

With similar sensitivity, patients more often labeled loads above the categorical border erroneously as belonging to category A, thus underestimating their resistance ( β = -0.06, p = .001; η2 = 0.02).

CONCLUSIONS

Individuals with PIA showed a systematic "wait and see" approach. Altered respiroception in PIA might stem from biased perception during training phase, the recognition phase, biased memory, or a combination of these. Its exact characteristics remain unknown, and future research must address the challenge of developing reliable and valid paradigms accounting for the variability of interoceptive biases.

REGISTRATION

This work was preregistered on OSF ( https://osf.io/9shcw ).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Somatic Symptom Disorder and Health Anxiety: Assessment and Management

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder (IAD) replaced the diagnostic entities of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) somatoform disorders and hypochondriasis. SSD turns away from specifying the presence or absence of a medical condition for presented symptoms and instead focuses on excessive symptom-related affects, cognitions, and behaviors. People with pathological health anxiety can be diagnosed with SSD or IAD, depending on the intensity of accompanying somatic symptoms. Cognitive-behavioral therapy shows the best empirical evidence for an effective treatment of SSD and IAD.

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

OBJECTIVE

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

DESIGN/SETTING

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

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSY-PSS)

Introduction

Numerous psychological factors are believed to play a pivotal role in the development and maintenance of persistent somatic symptoms (PSS) in all fields of medicine. However, very few of these factors have been empirically investigated in relation to PSS. The aim of this study is firstly to propose a framework and define search terms for systematic reviews on the empirical evidence and diagnostic value of psychological risk factors for PSS and PSS-related outcomes (PSY-PSS). Secondly, the application of the framework is illustrated using the example of a systematic review on the relevance of psychological factors in somatic symptom disorders (SSD; DSM-5) and bodily distress disorders (BDD; ICD-11).

Methods

Following a narrative review approach, two comprehensive lists of search terms to identify studies in (1) relevant patient groups with PSS and (2) relevant psychological factors were generated by reviewing the current literature and employing an iterative process of internal revision and external expert feedback.

Results

We identified 83 relevant symptoms, syndromes and disorders for which we defined a total of 322 search terms (list 1). We further comprised 120 psychological factors into 42 subcategories and 7 main categories (list 2). The introduced lists can be combined to conduct systematic reviews on one or more specific psychological factors in combination with any symptom, syndrome or disorder of interest. A protocol of the application of this framework in a systematic review and meta-analysis on psychological etiological factors of SSD and BDD is presented following the PRISMA guidelines.

Discussion

This framework will help to gather systematic evidence on psychological factors in order to improve the understanding of the etiology of PSS, to refine future diagnostic conceptualizations of PPS, and to develop optimized mechanism-based interventions for individuals with PPS and related syndromes and disorders.

Validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder and illness anxiety disorder in pathological health anxiety: Should we close the chapter?

OBJECTIVE

To investigate the validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder (SSD) and illness anxiety disorder (IAD) in pathological health anxiety: the excessive and recurrent fear of, or preoccupation with, having or developing a serious health condition.

METHODS

We compared SSD to IAD in pathological health anxiety (N = 334) with regard to concurrent, antecedent, and predictive validators. This was primarily a cross-sectional study, though we studied the effect of CBT longitudinally. Because we were interested in the discriminatory value of SSD and IAD over and above trait health anxiety, we used trait health anxiety as a covariate.

RESULTS

SSD (68%; 228/334) vs. IAD (32%; 106/334) differences were mostly non-significant and small in sociodemographics, core clinical characteristics, apparent course, etiological attribution, and physician visits (gs = -0.18-0.20; RRs = 0.84-1.09; IRRs = 0.87-0.99). However, SSD was associated with a significantly higher somatic symptom burden (gs = 0.20-0.72), more psychologist visits (IRR = 2.02, 95% CI: 1.24-3.28), and slightly higher disability (g = 0.22, 95% CI: 0.03-0.42). There was no significant difference in symptom reduction during CBT (g = -0.16, 95% CI: -0.37-0.05).

CONCLUSION

Although not all differences between SSD and IAD in pathological health anxiety seem to be explained by the level of trait health anxiety, the SSD vs. IAD distinction appears to convey little useful information in pathological health anxiety. Tentatively, considering the well-documented clinical characteristics and effective clinical interventions, it is probably most helpful to regard pathological health anxiety as a de facto anxiety or perhaps obsessive-compulsive spectrum disorder, regardless of the DSM-5 diagnosis of SSD or IAD.

Coping strategies among individuals with multiple physical symptoms: A general population-based cross-sectional study

OBJECTIVE

Coping has been suggested as a perpetuating factor for physical symptoms. The aim of this study was to examine the use of the coping strategies approach, resignation, and diversion in individuals with multiple physical symptoms according to the construct of Bodily Distress Syndrome (BDS).

METHODS

This cross-sectional study was part of the nationwide web-based survey Danish Symptom Cohort (DaSC). In total, 100,000 individuals were invited to participate, and individuals eligible for the present study were respondents aged 20-64 years without a current or recent pregnancy. Multiple physical symptoms were identified using the BDS checklist, and coping was assessed by the Brief Approach/Avoidance Coping Questionnaire. Statistical analyses included descriptive statistics and multinomial and logistic regression.

RESULTS

A total of 35,810 respondents were included in the study, of which 8512 (23.8%) fulfilled the criteria for having multiple physical symptoms. This group of respondents had lower coping scores on approach and higher coping scores on resignation and diversion compared with the non-BDS group. The regression analyses showed that high scores on approach were associated with a lower probability of having multiple symptoms (adjusted OR 0.92, 95% CI: 0.91-0.92), whereas high scores on diversion and resignation were associated with a higher probability of having multiple symptoms (adjusted OR 1.10; 95% CI: 1.09-1.11 and adjusted OR 1.19; 95% CI: 1.18-1.20, respectively).

CONCLUSION

The study supports the hypothesis that experiencing multiple physical symptoms is associated with certain coping strategies. This is relevant knowledge for health care professionals who will be treating this patient group.

Mental disorders are no predictors to determine the duration of cannabis-based treatment for chronic pain

Background

Chronic pain (CP), a complex biopsychosocial disorder with a global prevalence of up to 33%, can be treated by following multidisciplinary approaches that may include cannabis-based medicine (CBM). However, because CBM continues to be a new treatment, questions remain regarding the ideal duration for CBM and its psychosocial determinants, including mental comorbidities.

Methods

In a retrospective cross-sectional study involving 46 patients with CP (ICD-10 code F45.4-), three validated instruments-the German Pain Questionnaire, the Depression Anxiety Stress Scale (DASS), and the Marburg Questionnaire of Habitual WellBeing-were used to identify pain-specific psychosocial determinants and mental disorders. Descriptive analyses, a group differences analysis, and a logistic regression analysis were performed using SPSS.

Results

The patients most frequently reported low back pain as the primary location of their CP, and in attributing the condition to tissue damage, most had largely adopted a somatic orientation in conceptualizing their illness. Most had experienced CP for more than 5 years (M = 5.13 years, SD = 1.41) and, as a consequence, faced significant restrictions in their everyday life and exhibited low subjective wellbeing (MFHW median = 4.00, N = 43, Q1: 2.00, Q3: 9.00, range: 0-20). Comorbidities among the patients included depression, (DASS-Depression, median: 11.50, Q1: 7.00, Q3: 16.25), anxiety (DASS-Anxiety, median: 4.50, Q1: 2.75, Q3: 8.00), and stress (DASS-Stress, median: 11.00, Q1: 7.00, Q3: 15.00). Between the two cannabis-based treatments with a course lasting either less or more than a year, the duration of treatment showed no between-group differences in terms of sociodemographic factors, pain-specific factors, conceptualizations of the illness, or mental disorders. Psychosocial determinants such as subjective wellbeing and mental comorbidities were not significant predictors of the duration of cannabis-based treatment.

Conclusion

We found no evidence indicating that the benefits of short-term vs. long-term cannabis-based treatment can be predicted by mental comorbidities or psychosocial factors. However, because CBM may be included in approaches to treat CP, questions about the ideal duration of such treatment remain to be answered.

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.

Efficacy of Heart Rate Variability Biofeedback for Somatic Symptom Disorder: A Pilot Randomized Controlled Trial

OBJECTIVE

Patients with somatic symptom disorder (SSD) often receive targeted intervention only after a long duration of illness. Moreover, the reported effect sizes of interventions for SSD are small. Therefore, improvement and evaluation of interventions are needed. Preliminary evidence suggests autonomic imbalance, for example, lower heart rate variability (HRV) in SSD. HRV biofeedback (HRV-BF) as a method for self-regulation shows initial positive effects in chronic pain and functional syndromes. The aim of this study was to evaluate the efficacy of a brief HRV-BF intervention for SSD.

METHODS

Of a total of 50 participants with SSD ( Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ) who were recruited and randomly assigned to four sessions of HRV-BF ( n = 25) or autogenic training (AT; n = 25), 49 participants were analyzed (female, 77.6%; mean [standard deviation] age = 45.3 [14.4] years). The primary outcomes were somatic symptom severity (Screening for Somatoform Disorders, numeric rating scale) and HRV. Secondary outcomes were psychological characteristics of SSD (e.g., the Somatic Symptom Disorder 12 scale, health concerns, emotion regulation). The data were collected before and after intervention and were analyzed with repeated-measures analyses of variance and post hoc t tests.

RESULTS

Symptom severity improved after both, HRV-BF and AT. Standard Deviation of the NN Interval and psychological symptoms improved significantly more strongly in the HRV-BF than in the AT group (e.g., Standard Deviation of the NN Interval: ηp2 interaction = 0.10, p = .047).

CONCLUSIONS

The improvements in somatic symptoms, but specifically in cognitive-affective symptoms and autonomic regulation, suggest that HRV-BF with only four sessions is a potentially useful intervention option for SSD. Thus, adding this short HRV-BF intervention to existing psychological treatments for SSD may be promising.Trial Registration : German Clinical Trial Register identifier DRKS00017099 ( https://www.drks.de ).

Efficacy of mindfulness- and acceptance-based cognitive-behavioral therapies for bodily distress in adults: a meta-analysis

Objective

Bodily distress, i.e., somatoform disorders and associated functional somatic syndromes, is highly prevalent, often persistent and highly disabling. It has been proposed that "third wave" therapies may be beneficial variants of cognitive behavioral treatments. However, evidence on their efficacy is scarce. This meta-analysis examines the efficacy of "third wave" psychotherapies (mindfulness-based cognitive therapy [MBCT], mindfulness-based stress reduction [MBSR], and acceptance and commitment therapy [ACT]) in adults with bodily distress.

Method

We included randomized controlled trials (RCTs) treating adults with bodily distress using MBCT, MBSR, and ACT compared to inactive and non-specific control groups. A random effects model was used. The primary outcome was somatic symptom severity. Secondary outcomes were degrees of depression and of anxiety, health anxiety, perceived health status, mindfulness, psychological inflexibility, and pain acceptance.

Results

Sixteen RCTs with 1,288 participants were included in the analysis (k = 4 MBCT, k = 7 MBSR, k = 5 ACT; k = 7 fibromyalgia, k = 5 irritable bowel syndrome, k = 1 chronic fatigue syndrome, k = 2 bodily distress, k = 1 medically unexplained symptoms). However, not all studies provided data for each of the relevant outcomes. The analyses revealed that "third wave" therapies were more effective than control conditions in reducing somatic symptom severity (k = 15, n = 1,100, g = -0.51, 95%CI -0.69; -0.32). Heterogeneity was moderate (I ² = 52.8%, 95%CI 15.1 to 73.8). Effects for secondary outcomes were small to moderate with varying degrees of heterogeneity. We did not find differences between the different therapy approaches (mindfulness- vs. acceptance-based therapies); neither therapy dosis (i.e., total duration of therapy sessions) nor number of sessions were significant moderators of efficacy.

Conclusions

The therapies addressing mindfulness and acceptance proved to be more effective than control conditions. Hence, they are promising treatment approaches for bodily distress. However, there is still need for research on which patient groups may benefit from these psychological approaches.

Systematic review registration

https://osf.io/g7hby, identifier: 10.17605/OSF.IO/4RZGC.

Chronic Pain in the ICD-11: New Diagnoses That Clinical Psychologists Should Know About

Background

In the 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10), chronic pain was not represented adequately. Pain was left undefined and not recognized as a biopsychosocial phenomenon. Instead, a flawed dualism between psychological and somatic factors was implied. Individual diagnoses were ill-defined and scattered randomly through different chapters. Many patients received diagnoses in remainder categories devoid of meaningful clinical information.

Method

The International Association for the Study of Pain launched a Task Force to improve the diagnoses for the 11th revision of the ICD and this international expert team worked from 2013-2019 in cooperation with the WHO to develop a consensus based on available evidence and to improve the diagnoses.

Results

A new chapter on chronic pain was created with a biopsychosocial definition of pain. Chronic pain was operationalized as pain that persists or recurs longer than three months and subdivided into seven categories: Chronic primary pain and six types of chronic secondary pain. All diagnoses were based on explicit operationalized criteria. Optional extension codes allow coding pain-related parameters and the presence of psychosocial aspects together with each pain diagnosis.

Conclusion

First empirical studies demonstrated the integrity of the categories, the reliability, clinical utility, international applicability and superiority over the ICD-10. To improve reliability and ease of diagnosis, a classification algorithm is available. Clinical psychologists and other clinicians working with people with chronic pain should watch the national implementation strategies and advocate for multimodal and interdisciplinary treatments and adequate reimbursement for all providers involved.

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.

Using expectation violation models to improve the outcome of psychological treatments

Expectations are a central maintaining mechanism in mental disorders and most psychological treatments aim to directly or indirectly modify clinically relevant expectations. Therefore, it is crucial to examine why patients with mental disorders maintain dysfunctional expectations, even in light of disconfirming evidence, and how expectation-violating situations should be created in treatment settings to optimize treatment outcome and reduce the risk of treatment failures. The different psychological subdisciplines offer various approaches for understanding the underlying mechanisms of expectation development, persistence, and change. Here, we convey recommendations on how to improve psychological treatments by considering these different perspectives. Based on our expectation violation model, we argue that the outcome of expectation violation depends on several characteristics: features of the expectation-violating situation; the dynamics between the magnitude of expectation violation and cognitive immunization processes; dealing with uncertainties during and after expectation change; controlled and automatic attention processes; and the costs of expectation changes. Personality factors further add to predict outcomes and may offer a basis for personalized treatment planning. We conclude with a list of recommendations derived from basic psychology that could contribute to improved treatment outcome and to reduced risks of treatment failures.

Predictors of somatic symptom persistence in patients with chronic kidney disease (SOMA.CK): study protocol for a mixed-methods cohort study

INTRODUCTION

Seven of 10 patients with non-dialysis chronic kidney disease (CKD) experience burdensome persistent somatic symptoms (PSS). Despite the high prevalence and relevance for quality of life, disease progression and mortality, the pathogenesis of PSS in CKD remains poorly understood. The SOMA.CK study aims to investigate biopsychosocial predictors and their interactions for PSS in non-dialysis CKD and to develop a multivariate prognostic prediction model for PSS in CKD.

METHODS AND ANALYSIS

The study is a mixed-methods cohort study with assessments at baseline, 6 and 12 months. It aims to include 330 patients with CKD stages G2-4 (eGFR=15-89 mL/min/1.73 m²). Primary outcome is the CKD-specific somatic symptom burden assessed with the CKD Symptom Burden Index. Secondary outcomes include quality of life, general somatic symptom burden and functioning. The interplay of biomedical (eg, biomarkers, epigenetics), treatment-related (eg, therapies and medication) and psychosocial variables (eg, negative affectivity, expectations) will be investigated to develop a prognostic prediction model for PSS. In an embedded mixed-methods approach, an experimental study in 100 patients using an affective picture paradigm will test the effect of negative affect induction on symptom perception. An embedded longitudinal qualitative study in 40-50 newly diagnosed patients will use thematic analysis to explore mechanisms of symptom development after receiving a CKD diagnosis. SOMA.CK is part of the interdisciplinary research unit 'Persistent SOMAtic Symptoms ACROSS Diseases'.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10195-BO-ff). Findings will be disseminated through peer-reviewed publications, scientific conferences, the involvement of our patient advisory board and the lay public. Focusing on subjective symptom burden instead of objective disease markers will fundamentally broaden the understanding of PSS in CKD and pave the path for the development of mechanism-based tailored interventions.

TRIAL REGISTRATION NUMBER

ISRCTN16137374.

From the identification of biopsychosocial risk factors to an increase in pain-related self-efficacy (IDRIS) - The online-based conveyance of an explanatory model for chronic back pain: Study protocol of a cohort multiple randomized controlled trial

BACKGROUND

Back pain has a high global prevalence and carries a substantial risk for chronification. Biopsychosocial factors are assumed to be critical in the transition from acute to chronic back pain. Digital interventions are a promising tool to educate patients about their complaints. Thus, providing patients with an explanatory model regarding their individual risk factors in the early stage of their complaints via the internet might thus be a valuable approach in treatment.

OBJECTIVES

The objectives of the present online study are to investigate the influence of a personalized psychoeducational intervention on self-efficacy and functioning and to examine biopsychosocial risk factors for symptom chronification. The intervention is based on a current model summarizing the empirical knowledge on relevant factors for persistent somatic symptoms, which has not been studied in back pain patients yet.

METHODS

An observational cohort of patients with acute and subacute back pain (N = 564) will be asked about biopsychosocial risk factors via online survey at baseline, 4-week, and 12-week follow-up. Within this cohort, a randomly selected group of 132 participants (intervention group) with psychological burden (MCS-12 score of the SF-12 ≤ 50) and relevant somatic symptom intensity and interference (mean sum score of two numeric rating scales ≥5) and no prior psychotherapeutic treatment will be offered a personalized explanatory model in the form of an animated psychoeducational video. The video will be personalized in terms of participants' individual symptom profile and will be made accessible to watch online for 7 days. Participants will be compared to a control group receiving no treatment regarding change in pain-specific self-efficacy after 1 month as primary outcome, and change in functioning after 1 and 3 months, respectively, as secondary outcomes. Acceptance and usefulness of the intervention will be evaluated using the number of video views and a numeric rating scale.

DISCUSSION

This is the first investigation of a personalized, video-animated online psychoeducation based on patients' individual risk factors for the chronification of back pain and the first systematic evaluation of the risk factors included in a comprehensive aetiological model on persistent somatic symptoms in back pain patients. This way, this study contributes to the understanding of cross-disorder psychopathological factors and a stronger consideration of biopsychosocial factors in the treatment of persistent somatic symptoms. If proven effective, the internet-based intervention will make an important contribution to the early treatment of back pain.

ETHICAL APPROVAL

The study was approved by the Local Psychological Ethics Committee (LPEK) at the Center for Psychosocial Medicine of the University Medical Center Hamburg-Eppendorf.

TRIAL REGISTRATION

The study was registered at the German Clinical Trials Register in December 2021 (registration trial number: DRKS00025445).

Risk factors for worsening of somatic symptom burden in a prospective cohort during the COVID-19 pandemic

Introduction

Little is known about risk factors for both Long COVID and somatic symptoms that develop in individuals without a history of COVID-19 in response to the pandemic. There is reason to assume an interplay between pathophysiological mechanisms and psychosocial factors in the etiology of symptom persistence.

Objective

Therefore, this study investigates specific risk factors for somatic symptom deterioration in a cohort of German adults with and without prior SARS-CoV-2 infection.

Methods

German healthcare professionals underwent SARS-CoV-2 IgG antibody testing and completed self-rating questionnaires at baseline and 21 months later between April 2020 and February 2022. Differences in variables between the time points were analyzed and a regression analysis was performed to predict somatic symptom deterioration at follow-up.

Results

Seven hundred fifty-one adults completed both assessments. Until follow-up, n = 58 had contracted SARS-CoV-2 confirmed by serology. Between baseline and follow-up, signs of mental and physical strain increased significantly in the sample. Symptom expectations associated with COVID-19 and a self-reported history of COVID-19, but not serologically confirmed SARS-CoV-2 infection, significantly predicted somatic symptom deterioration at follow-up. A further predictor was baseline psychological symptom burden.

Conclusions

This study supports a disease-overarching biopsychosocial model for the development of burdensome somatic symptoms during the COVID-19 pandemic and supports research findings that symptom burden may be more related to the psychosocial effects of the pandemic than to infection itself. Future studies on Long COVID should include SARS-CoV-2 negative control groups and consider symptom burden prior to infection in order to avoid an overestimation of prevalence rates.

Estimated frequency of somatic symptom disorder in general practice: cross-sectional survey with general practitioners

BACKGROUND

Somatic symptom disorder (SSD) is the successor diagnosis of somatoform disorder in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Relevance and frequency of SSD and its clinical symptoms in general practice are still unknown. We estimate frequencies of patients fulfilling the diagnostic criteria of SSD in general practice.

METHODS

Mailed and online survey with general practitioners (GP) in Germany using a cross-sectional representative sample from registries of statutory health insurance physicians. GPs estimated percentages of their patients who show the clinical symptoms of SSD according to DSM-5; that is, one or more burdensome somatic symptoms (A criterion), excessive symptom- or illness-related concern, anxiety, or behaviour (B criterion), and persistence of the symptoms over at least 6 months (C criterion). Statistical analysis used means and confidence intervals of estimated patient proportions showing SSD symptoms. Frequency of full-blown SSD was based on the products of these proportions calculated for each GP.

RESULTS

Responses from 1728 GPs were obtained. GPs saw the clinical symptoms of SSD fulfilled (A and B criteria) in 21.5% (95% CI: 20.6 to 22.3) of their patients. They further estimated that in 24.3% (95% CI: 23.3 to 25.2) of patients, symptoms would persist, yielding a total of 7.7% (95% CI: 7.1 to 8.4) of patients to have a full-blown SSD.

CONCLUSIONS

We estimate a frequency of 7.7% of patients in general practice to fulfil the diagnostic criteria of SSD. This number may figure as a reference for the yet to be uncovered prevalence of SSD and it indicates a high clinical relevance of the clinical symptoms of SSD in general practice.

REGISTRATION

German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS).

DRKS-ID

DRKS00012942. The date the study was registered: October 2nd 2017. The date the first participant was enrolled: February 9th 2018.

Psychometric properties of the Persian version of the somatic symptom disorder-B Criteria Scale (SSD-12) in community and clinical samples

OBJECTIVE

In the DSM-5's diagnostic criteria of somatic symptom disorders (SSD), the presence of psychological problems (i.e., excessive thoughts, feelings, or behaviors) is emphasized more than the absence of the medical causes of patients' bothersome symptoms. In this regard, the Somatic Symptom Disorder-B Criteria Scale (SSD-12) is a screening tool for assessing these psychological features in somatic symptom disorder. This study aimed to validate the Persian version of SSD-12 in the Iranian community (non-clinical) and clinical samples.

METHODS

Data was gathered from 291 individuals in a community sample (aged 18 to 54, M-age = 36.62, SD = 10.56, 79.7% females) and from clinical setting, including 118 patients diagnosed with major depressive disorder (MDD, aged 18 to 60, M-age = 36.52, SD = 11.39, 75.8% females) and 120 patients diagnosed with somatic symptom disorders (aged 18 to 60, M-age = 35.17, SD = 8.77, 73.7% females). To assess the convergent validity of SSD-12 in the clinical samples, participants were asked to complete measures assessing anxiety, depression, somatic symptoms, health anxiety, and emotional regulation.

RESULTS

Confirmatory Factor Analyses (CFAs) showed that the three-factor model of the SSD-12 reached acceptable fit in the community and clinical samples and yielded excellent internal consistency across the samples. Also, test-retest reliability analysis results were good in the community sample. Convergent validity could be shown in the clinical samples. A cut-off score greater than 14 was in the optimal state with a sensitivity of 70.83 and a specificity of 70.07.

CONCLUSION

The current study provides evidence on the factor structure, reliability, and validity of the Persian SSD-12 in the Iranian community and clinical samples. A sum score of 14 can be recommended as the cut-off point. Further studies are needed to assess SSD-12 in different clinical populations and larger samples.

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.

Increased spontaneous fronto-central oscillatory power during eye closing in patients with multiple somatic symptoms

Functional somatic symptoms (FSS) are typically associated with excessive thoughts, feelings and behaviors related to the physical symptoms whether these symptoms are unequivocally associated with a diagnosed medical condition. However, less evidence is available concerning the neurocognitive deficits underlying these features of FSS. This study aimed to examine the resting-state oscillatory activities during both eye-opening and eye-closure states in individuals with FSS. Sixty-six FSS patients screened with PHQ-15 received two 10-minute sessions of EEG assessments. All completed clinical measurements on depression, anxiety, and psychological measurements on personality traits and alexithymia. Patients scoring high on PHQ-15 (the multiple somatic symptom (MSS) or SS-high group) demonstrated increased powers in central channels (C3 and C4) in low-beta band and in the left-frontal channel (F3) in high-gamma band, during eye-closure states. Patients with higher scores in depression were more likely to be classified as the SS-high group. SS-high patients demonstrated increased difficulties in describing and identifying emotions, and less reduced day-dreaming. The combined findings in increased fronto-central high-frequency activities and alexithymia measures suggest MSS patients are associated with enhanced internally-oriented thinking and cognitive simulation which may lead to intensified feelings of simulated events and misattribution of symptoms. Future treatments should focus on eliminating cognitive bias and enhancing accuracy in interoceptive awareness.

A unified Internet-delivered exposure treatment for undifferentiated somatic symptom disorder: single-group prospective feasibility trial

BACKGROUND

Exposure-based psychological treatment appears to have beneficial effects for several patient groups that commonly report distress related to persistent somatic symptoms. Yet exposure-based treatment is rarely offered in routine care. This may be because existing treatment protocols have been developed for specific symptom clusters or specific unwanted responses to somatic symptoms, and many clinics do not have the resources to offer all these specialised treatments in parallel. In preparation for a randomised controlled trial, we investigated the feasibility of a new and unified Internet-delivered exposure treatment (OSF.io: cnbwj) for somatic symptom disorder regardless of somatic symptom domain (e.g. cardiopulmonary, fatigue, gastrointestinal, pain), combination of unwanted emotions (e.g. anger, anxiety, fear, shame) and whether somatic symptoms are medically explained or not. We hypothesised that a wide spectrum of subgroups would show interest, that the treatment would be rated as credible, that adherence would be adequate, that the measurement strategy would be acceptable and that there would be no serious adverse events.

METHODS

Single-group prospective cohort study where 33 self-referred adults with undifferentiated DSM-5 somatic symptom disorder took part in 8 weeks of unified Internet-delivered exposure treatment delivered via a web platform hosted by a medical university. Self-report questionnaires were administered online before treatment, each week during treatment, post treatment and 3 months after treatment.

RESULTS

Participants reported a broad spectrum of symptoms. The Credibility/Expectancy mean score was 34.5 (SD = 7.0, range: 18-47). Participants completed 91% (150/165) of all modules and 97% of the participants (32/33) completed at least two exposure exercises. The average participant rated the adequacy of the rationale as 8.4 (SD = 1.5) on a scale from 0 to 10. The post-treatment assessment was completed by 97% (32/33), and 84% (27/32) rated the measurement strategy as acceptable. The Client Satisfaction Questionnaire mean score was 25.3 (SD = 4.7, range: 17-32) and no serious adverse events were reported. Reductions in subjective somatic symptom burden (the Patient Health Questionnaire 15; d = 0.90) and symptom preoccupation (the somatic symptom disorder 12; d = 1.17) were large and sustained.

CONCLUSIONS

Delivering a unified Internet-delivered exposure-based treatment protocol for individuals with undifferentiated somatic symptom disorder appears to be feasible.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04511286 . Registered on August 13, 2020.

Prevalence of DSM-5 somatic symptom disorder in Chinese patients with breast cancer

OBJECTIVE

The aims of this study were to explore the frequency of somatic symptom disorder (SSD) and the relationship between SSD and somatic, psychological, and social factors in Chinese patients with breast cancer.

METHODS

This multicenter cross-sectional study enrolled 264 patients with breast cancer from 3 different departments in Beijing. The structured clinical interview for DSM-5 (SCID-5) for SSD. Standardized questionnaires and clinical data were used to compare patients with and without SSD.

RESULTS

SSD was diagnosed in 21.6% (57/264) of all enrolled patients. No differences were found between SSD patients and non-SSD patients in terms of sociodemographic characteristics and tumor-specific variables, except radiotherapy.However, patients with SSD reported higher levels of depression, anxiety and cancer-related worry. They also showed a longer duration of symptoms, greater impairment in daily life, more concern over their physical complaints and more doctor visits. In a stepwise binary logistic regression analysis, among others, higher health anxiety (WI-8, Exp(B) = 0.107, p = 0.009) and more doctor visits (OR = -1.841, p < 0.001) showed a significant association with SSD; the model explained 53.7% of the variance.

CONCLUSIONS

Similar to other physical diseases, there is a high prevalence of SSD in patients with breast cancer. SSD patients differ from non-SSD patients by exhibiting higher cancer-related emotional distress and dysfunctional illness perception and behavior. There remain substantial challenges in the diagnosis of SSD in patients with cancer and other medical conditions. This article is protected by copyright. All rights reserved.

Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis

BACKGROUND

In 2013, the diagnosis of somatic symptom disorder (SSD) was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This review aims to comprehensively synthesize contemporary evidence related to SSD.

METHODS

A scoping review was conducted using PubMed, PsycINFO, and Cochrane Library. The main inclusion criteria were SSD and publication in the English language between 01/2009 and 05/2020. Systematic search terms also included subheadings for the DSM-5 text sections; i.e., diagnostic features, prevalence, development and course, risk and prognostic factors, culture, gender, suicide risk, functional consequences, differential diagnosis, and comorbidity.

RESULTS

Eight hundred and eighty-two articles were identified, of which 59 full texts were included for analysis. Empirical evidence supports the reliability, validity, and clinical utility of SSD diagnostic criteria, but the further specification of the psychological SSD B-criteria criteria seems necessary. General population studies using self-report questionnaires reported mean frequencies for SSD of 12.9% [95% confidence interval (CI) 12.5-13.3%], while prevalence studies based on criterion standard interviews are lacking. SSD was associated with increased functional impairment, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Relevant research gaps remain regarding developmental aspects, risk and prognostic factors, suicide risk as well as culture- and gender-associated issues.

CONCLUSIONS

Strengths of the SSD diagnosis are its good reliability, validity, and clinical utility, which substantially improved on its predecessors. SSD characterizes a specific patient population that is significantly impaired both physically and psychologically. However, substantial research gaps exist, e.g., regarding SSD prevalence assessed with criterion standard diagnostic interviews.

Individual treatment goals and factors influencing goal attainment in patients with somatic symptom disorder from the perspective of clinicians: A concept mapping study

OBJECTIVE

Overviews of treatment goals and influencing factors may support shared decision making and optimize customized treatment to the patient with somatic symptom disorder (SSD). The aim of this study was to identify and structure comprehensive sets of treatment goals and factors influencing goal attainment in patients with SSD from the perspective of clinicians.

METHODS

Using a concept mapping procedure, clinicians participated in interviews (N = 17) and card sorting tasks comprising 55 treatment goals and 55 factors influencing goal attainment (N = 38).

RESULTS

We identified four overarching categories (A to D) of nine clusters (1 to 9) of treatment goals: A. empowerment (A1. personal values, A2. committed action, A3. self-esteem), B. skill improvement (B4. interpersonal skills, B5. emotion and stress regulation), C. symptom reduction (C6. dysfunctional beliefs, C7. somatic symptoms, C8. psychological symptoms), and D9. active and structured lifestyle. Also, we identified four overarching categories (A to D) of nine clusters (1 to 9) of factors influencing goal attainment: A1. therapeutic alliance, B. social and everyday context (B2. [family] system, B3. meaningful daily schedule, B4. social and economic circumstances), C. ability to change (C5. externalizing tendency, C6. reflective and psychological skills, C7. perspective and motivation), and D. psychological vulnerability (D8. vulnerable personality, D9. [psychiatric] comorbidity).

CONCLUSION

The overviews of treatment goals and factors influencing goal attainment reflect different paradigmatic backgrounds of clinicians. The results can be used, in combination with the perspective of the patient, to define treatment goals, and to monitor and evaluate change in outcomes.

Persistent SOMAtic symptoms ACROSS diseases - from risk factors to modification: scientific framework and overarching protocol of the interdisciplinary SOMACROSS research unit (RU 5211)

INTRODUCTION

Persistent somatic symptoms (PSS) are highly prevalent in all areas of medicine; they are disabling for patients and costly for society. The subjective symptom burden often correlates poorly with the underlying disease severity, and patients' needs for effective treatment are far from being met. Initial evidence indicates that, in addition to disease-specific pathophysiological processes, psychological factors such as expectations, somatosensory amplification and prior illness experiences contribute to symptom persistence in functional as well as in somatic diseases. However, prospective studies investigating the transition from acute to chronic somatic symptoms, integrating pathophysiological, psychological and social factors, are scarce. A better understanding of the multifactorial mechanisms of symptom persistence is crucial for developing targeted mechanism-based interventions for effective prevention and treatment of PSS. Thus, the overall aim of the interdisciplinary SOMACROSS research unit is to identify generic and disease-specific risk factors and aetiological mechanisms of symptom persistence across a range of diseases.

METHODS AND ANALYSIS

Seven projects will investigate risk factors and mechanisms of symptom persistence in a total of 3916 patients across 10 medical conditions. All study designs are prospective and share common assessment points, core instruments and outcome variables to allow comparison and validation of results across projects and conditions. Research will focus on the identification of generic and disease-specific mechanisms associated with unfavourable symptom course. The development of a multivariate prediction model will facilitate the understanding of the course of PSS across diseases.

ETHICS AND DISSEMINATION

All individual SOMACROSS studies were approved by the ethics committees of the Medical Chambers Hamburg and Münster, Germany. Findings will be disseminated through peer-reviewed publications, scientific conferences and the involvement of relevant stakeholders, patients and the lay public. This interdisciplinary research unit will fundamentally contribute to earlier recognition of patients at risk, and to the development of prevention and tailored treatment concepts for PSS.

Psychobiological Mechanisms in Somatic Symptom Disorder and Depressive Disorders: An Ecological Momentary Assessment Approach

OBJECTIVE

Persistent somatic symptoms cause strong impairment in persons with somatic symptom disorder (SSD) and depressive disorders (DDs). Specific negative psychological factors (NPFs), such as catastrophizing, negative affectivity, and behavioral avoidance, are assumed to contribute to this impairment and may maintain symptoms via dysregulations of biological stress systems. We examined the associations between NPF and somatic symptoms in the daily life of women with SSD or DD and investigated the mediating role of psychobiological stress responses.

METHODS

Twenty-nine women with SSD and 29 women with DD participated in an ecological momentary assessment study. For 14 days, intensity of and impairment by somatic symptoms, NPF, and stress-related biological measures (cortisol, alpha-amylase) were assessed five times per day using an electronic device and saliva samples. Multilevel models were conducted.

RESULTS

The greater the number of NPF, the higher the concurrent and time-lagged intensity of and impairment by somatic symptoms in both groups (12.0%-38.6% of variance explained; χ2(12) p < .001 for all models). NPFs were associated with higher cortisol levels in women with DD and with lower levels in women with SSD (interaction NPF by group: B = -0.04, p = .042 for concurrent; B = -0.06, p = .019 for time-lagged). In women with SSD, lower cortisol levels were associated with higher intensity at the next measurement time point (group by cortisol: B = -1.71, p = .020). No mediation effects were found.

CONCLUSIONS

NPFs may be considered as transdiagnostic factors in the development and treatment of impairing somatic symptoms. Our findings will allow the development of new treatment strategies that use ecological momentary intervention approaches focusing on NPF.

Somatization and Somatic Symptom Disorder and its overlap with dimensionally measured personality pathology: A systematic review

OBJECTIVE

Difficulties in the assessments of Somatoform Disorders (SD) and Personality Disorders (PD) regarding operationalization, arbitrary thresholds, and reliability led to a shift from categorical to dimensional models in the DSM-5. Empirical research data postulates a continuous level of severity in both groups of diseases. The aim of this systematic review was to investigate the overlap between somatization and personality pathology.

METHODS

Until July 2020, we conducted a systematic literature search with PubMed, Web of Science and SCOPUS. We specifically reviewed current empirical data on the Alternative Model of Personality Disorders (AMPD) and Somatic Symptom Disorder (SSD) and SD. Data was drawn out using predefined data panels. Results were reflected in the context of the Hierarchical Taxonomy of Psychopathology (HiTOP) model. Risk of bias was assessed due to blinding, randomization, selective reporting, incomplete data, and attribution bias.

RESULTS

A total of eight studies (N = 2979) met the inclusion criteria. Whereas categorical measures revealed mixed results, positive correlations between SD/SSD and dimensionally measured personality functioning were present in four studies (N = 1741). In three studies (N = 2025) correlations between SD/SSD and neuroticism/negative affectivity (d = 0.22-1.041) were present. Moreover, harm avoidant (d = 0.526 - 0.826) and self-defeating traits (d = 0.892) revealed significant associations with somatization.

CONCLUSIONS

Dimensional personality assessments are highly neglected in patients with SSD and warrant further research. However, in line with the HiTOP model, there is tentative evidence that somatization can be described as an independent personality trait, which shows most striking overlaps with self-pathologies (Criterion A) and the trait of negative affectivity (Criterion B).

Subjective versus objective measures of distress, arousal and symptom burden in patients with functional seizures and other functional neurological symptom disorder presentations: A systematic review

Symptoms and functioning can be measured subjectively using self-report measures or objectively, based on physiological changes. This raises the question whether subjective and objective measures are closely correlated and - if not - whether one is more accurate or meaningful than the other, especially in patients with Functional Seizures (FS) or other Functional Neurological Symptom Disorders (FND), where subjective and objective observations may be thought particularly likely to deviate. This systematic review explores these questions focussing on measures of distress, arousal and symptom burden. Eighteen studies (12 FS, 6 other FND) capturing 396 FND patients were included. Eleven reported no correlation between subjective and objective measures. Only four studies reported significant correlations (r's = -0.74-0.59, p's < 0.05). The small number of studies and diverse methodologies do not provide conclusive answers to the questions posed. Given that subjective and objective measures capture different aspects of current state or function, a combination of measurement approaches is likely to provide optimal information about patients' health state. In view of the attentional and perceptual alterations implicated in FND, the difference between objective and subjective measures may represent an interesting observation in its own right.

Persistence rate of DSM-5 somatic symptom disorder: 4-year follow-up in patients from a psychosomatic outpatient clinic

BACKGROUND

Somatic Symptom and Related Disorders (SSD) were introduced by DSM-5 in order to improve the classification of somatoform disorders. There is a lack of longitudinal studies on course and predictors of SSD. The present study investigates the natural course of SSD in a four-year follow-up study in patients from a psychosomatic outpatient clinic.

MATERIAL AND METHODS

At baseline, n = 360 outpatients completed a semi-structured clinical interview to assess SSD, and additional self-report questionnaires (SSS-8, SSD-12, PHQ-8, GAD-7, SF-12). 112 patients were re-assessed after four years. Persistence rate and predictors for persisting SSD were evaluated.

RESULTS

The prevalence rate of SSD at baseline was 51.8%, and 47.3% at follow-up. We found a persisting SSD in 30.4% (n = 34) of the patients, a remission rate of 21.4% (n = 24) and an incidence rate of 16.9% (n = 19). 31.3% (n = 35) of the sample never received a SSD diagnosis. Significant predictors for persistence were a high psychological burden through somatic symptoms (OR: 1.13, 95% CI: 1.01-1.26) and general anxiety (OR: 1.38, 95% CI: 1.01-1.88) at baseline.

CONCLUSION

This study indicates that SSD is highly prevalent and persistent in patients from a psychosomatic setting. Our findings indicate that psychological and behavioral factors contribute to the maintenance of SSD and present potential targets for interventions. Future interventions for SSD could potentially be optimized by addressing psychological processes such as catastrophic thinking styles and symptom focusing.

The association of childhood maltreatment, somatization and health-related quality of life in adult age: Results from a population-based cohort study

BACKGROUND

Population-based data regarding the relationship between childhood maltreatment (CM), somatization and health-related quality of life (HRQoL) in adults are limited.

OBJECTIVE

To investigate the association of CM history (emotional and physical abuse and neglect, sexual abuse) with somatization and with physical and mental HRQoL in adults.

PARTICIPANTS AND SETTING

Data from 2305 participants from the population-based Study of Health in Pomerania were analyzed (aged 20 to 80 years).

METHODS

We applied the Childhood Trauma Questionnaire. Somatoform disorders were diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) in a clinical interview. Using a self-administered questionnaire, we assessed the number of somatic symptoms and physical and mental HRQoL.

RESULTS

Sexual abuse was related to the diagnosis of a somatoform disorder (odds ratio [OR] 1.87; 95% confidence interval [CI] 1.29, 2.69). Emotional abuse and physical neglect were associated with the number of somatic symptoms (B = 0.93; 95% CI 0.42, 1.45 and B = 0.50; 95% CI 0.17, 1.83, respectively). Sexual abuse and physical neglect were related to lower physical HRQoL (B = -1.87; 95% CI -3.17, -0.57 and B = -1.26; 95% CI -2.02, -0.49, respectively), and emotional abuse was associated with lower mental HRQoL (B = -2.83; 95% CI -4.03, -1.62).

CONCLUSIONS

A history of CM, in particular sexual abuse, emotional abuse and physical neglect, is a risk factor for somatization and impaired HRQoL in adults. Individuals with somatic symptoms are an important target group for CM screening. Addressing HRQoL might be significant in psychotherapy for individuals with CM experience.

Identifying persistent somatic symptoms in electronic health records: exploring multiple theory-driven methods of identification

OBJECTIVE

Persistent somatic symptoms (PSSs) are defined as symptoms not fully explained by well-established pathophysiological mechanisms and are prevalent in up to 10% of patients in primary care. The present study aimed to explore methods to identify patients with a recognisable risk of having PSS in routine primary care data.

DESIGN

A cross-sectional study to explore four identification methods that each cover part of the broad spectrum of PSS was performed. Cases were selected based on (1) PSS-related syndrome codes, (2) PSS-related symptom codes, (3) PSS-related terminology and (4) Four-Dimensional Symptom Questionnaire scores and all methods combined.

SETTING

Coded electronic health record data were extracted from 76 general practices in the Netherlands.

PARTICIPANTS

Patients who were registered for at least 1 year during 2014-2018, were included (n=169 138).

OUTCOME MEASURES

Identification methods were explored based on (1) PSS sample sizes and demographics, (2) presence of chronic conditions and (3) healthcare utilisation (HCU) variables. Overlap between methods and practice specific differences were examined.

RESULTS

The percentage of cases identified varied between 0.3% and 7.0% across the methods. Over 58.1% of cases had chronic physical condition(s) and over 33.8% had chronic mental condition(s). HCU was generally higher for cases selected by any method compared with the total cohort. HCU was higher for method B compared with the other methods. In 26.7% of cases, cases were selected by multiple methods. Overlap between methods was low.

CONCLUSIONS

Different methods yielded different patient samples which were general practice specific. Therefore, for the most comprehensive data-based selection of PSS cases, a combination of methods A, C and D would be recommended. Advanced (data-driven) methods are needed to create a more sensitive algorithm for identifying the full spectrum of PSS. For clinical purposes, method B could possibly support screening of patients who are currently missed in daily practice.

The role of cognitive factors in differentiating individuals with somatoform disorders with and without depression

The present study, based on a cross-sectional design, was conducted in the primary care setting with patients presenting somatic symptoms suggestive of somatoform disorders (SFD). The main aim of the study was to determine whether cognitive variables could differentiate between patients with SFD alone and those who also present depressive symptoms suggestive of depression (SFD + depression). All participants (N = 796) completed validated self-report measures to assess somatic, depressive, and/or anxiety symptoms, as well as functional impairment, quality of life (QoL), and cognitive variables (worry, rumination, metacognition, cognitive distortions, and emotion regulation). Univariate and multivariate analyses (controlled for potential sociodemographic and clinical confounders) were performed. On the univariate analysis, significant differences between the SFD and SFD + depression groups were found in sociodemographic and clinical variables, functional impairment, QoL, and cognitive variables. On the multivariate analysis, the only significative variables associated with comorbid SFD + depression were anxiety (β = 0.27; p < 0.001), physical and psychological QoL (β = -0.10; p = 0.01; and β = -0.21; p < 0.001, respectively), and marital status (β = -65; p < 0.05). Cognitive variables were not significantly related to depressive symptoms in patients with SFD. These findings suggest that patients with SFD - with or without comorbid depression - share common cognitive processes and thus both groups could benefit from transdiagnostic cognitive therapy.

The Validity of Somatic Symptom Disorder in Patients With Gastrointestinal Complaints

BACKGROUND AND GOAL

The current diagnostic concept of somatic symptom disorder (SSD) aims to capture psychological burden due to bodily complaints independent of the medical cause. The aim of this study was to compare patients with chronic gastrointestinal (GI) complaints with SSD (SSD+) and without SSD (SSD-) along sociodemographic, clinical, and psychological characteristics.

STUDY

This cross-sectional study included 199 patients (n=92 SSD+ and n=107 SSD-) with distressing and chronic abdominal/lower GI complaints (≥6 mo) recruited from several primary, secondary, and tertiary medical care units. SSD+ patients were separated from SSD- patients by psychobehavioral positive criteria. Psychological distress (somatization, depression, anxiety, and illness anxiety) and risk factors (adverse childhood experiences, insecure attachment, mentalizing capacity, and levels of personality functioning) were measured. Nonparametric group comparisons were performed to analyze the differences of sociodemographic, clinical, and psychological characteristics between SSD+ and SSD- patients.

RESULTS

About half of the SSD+ patients had a functional GI disorder and a third had an inflammatory bowel disease. SSD+ patients reported higher GI pain severity, higher health-related and work-related impairment, and higher psychological distress, especially illness anxiety, as well as higher mentalizing and personality functioning deficits.

CONCLUSIONS

Overall, psychobehavioral positive criteria of SSD seem to be a valid identifier of patients exhibiting a high psychological burden, independent of the medical explanation of the GI complaints. There is a substantial overlap of SSD and general mental burden, but also evidence for a specific disease entity.

Decline of anterior cingulate functional network efficiency in first-episode, medication-naïve somatic symptom disorder and its relationship with catastrophizing

The high prevalence of somatic symptom disorder (SSD) led to cumulative burdens to the medical system. However, the pathogenesis of this disease still remains unclear. Graph theoretical analysis discovered altered network topology across various psychiatric disorders, yet alteration in the topological structure of brain functional network in SSD patients is still unexplored. Catastrophizing is a common cognitive distortion in SSD. We hypothesize that the network topological metrics of SSD should be altered, and should correlate with catastrophizing scales. 32 medication-naïve, first-episode SSD patients and 30 age, gender matched HCs were recruited. The 17-item Hamilton Depression Rating Scale (HAMD-17), Hamilton Anxiety Rating Scale (HAMA) and Cognitive Emotion Regulation Questionnaire (CERQ) were accessed. Functional MRI were scanned and brain functional networks were constructed based on 166 anatomically cerebrum regions from the automated anatomical labeling 3 (AAL3) template. Network topological metrics were calculated and compared between the two groups. Correlation between these metrics and clinical scales were also calculated. Network global efficiency of SSD was significantly lower than that of HC. Nodal global efficiency of the left subgenual anterior cingulate cortex (sgACC) of SSD was significantly lower than that of HC. FCs between the left sgACC and other 21 seed nodes were significantly declined in SSD in comparison with HC. In SSD group, HAMD total score was significantly negatively correlated with the connection between the left medial superior frontal gyrus and the left sgACC. CERQ catastrophizing score was significantly negatively correlated with nodal global efficiency of left sgACC and with the FCs between the left sgACC and other 13 seed nodes. Catastrophizing could reflect the specific sgACC-centered dysfunction of brain network global efficiency of SSD. The left sgACC may be a future treatment target of dealing with catastrophizing, which is a core cognitive distortion of SSD.