Consultation-liaison psychiatrists' management of somatoform disorders

Illness Anxiety Disorder: Psychopathology, Epidemiology, Clinical Characteristics, and Treatment

Illness anxiety disorder is a primary disorder of anxiety about having or developing a serious illness. The core feature is the cycle of worry and reassurance seeking regarding health, as opposed to a focus on relief of distress caused by somatic symptoms (as in Somatic Symptom Disorder). Clinically significant health anxiety is common, with estimates ranging up to 13% in the general adult population. There are evidence-based treatments, including psychopharmacology and cognitive behavioral therapy, that can significantly alleviate symptoms. An understanding of the core psychopathology and clinical features of illness anxiety disorder is essential to fostering a working alliance with patients with health anxiety, as is the maintenance of an empathic, curious, and nonjudgmental stance toward their anxiety. Collaboration between medical providers is essential to avoid the pitfalls of excess testing and medical treatment.

Altered Brain Functional Hubs and Connectivity Underlie Persistent Somatoform Pain Disorder

This study investigated the degree of brain functional impairment in persistent somatoform pain disorder (PSPD) by examining changes in the patterns of brain functional hubs. Resting-state functional magnetic resonance imaging was performed in 21 PSPD patients with headache as the main symptom and 17 sex- and age-matched healthy controls. Degree centrality (DC) analysis as well as the connectivity among these hubs by functional connectivity (FC) analysis and Granger causality analysis (GCA) were performed to characterize abnormal brain networks in PSPD (Gaussian random field corrected: P < 0.001, Z > 3.09). The relationships between DC and connectivity and clinical parameters were also examined. DC values in the bilateral inferior occipital gyrus (IOG), bilateral calcarine fissure (CAL), and left paracentral lobule (PCL) and FC values of right IOG–left CAL, right IOG–right CAL, right IOG–left IOG, left CAL–right CAL, left CAL–left IOG, left CAL–left PCL, right CAL–left PCL, and left IOG–left PCL were lower in PSPD patients as compared to controls. A negative causal effect from the left CAL to the left paracentral lobule and a positive effect from the right CAL to the right IOG were observed in PSPD patients. Abnormal DC, FC, and signed-path coefficients in PSPD patients were negatively correlated with self-rating anxiety and depression scale scores. These results indicate that altered functional hubs and connectivity patterns in the somatosensory cortex may reflect emotional disturbance in PSPD patients.

Factors influencing quality of life in Chinese patients with persistent somatoform pain disorder

This cross-sectional survey aimed to explore quality of life (QoL) and its correlated factors in Chinese patients with persistent somatoform pain disorder (PSPD) and their related correlation factors in Shanghai, China. A total of 60 patients were assessed with Short Form (36) health survey (SF-36) for QoL, medical outcomes study pain measurement (MOSPM) for pain symptoms, Hamilton depression scale - 17 items (HAMD) for depression and Hamilton anxiety scale (HAMA) for anxiety. Results were as follows: (1) Patients scored significantly lower on all SF-36 subscales' scores ( p < .01) apart from the mental health and vitality subscales; (2) With the exception of the general health subscale, SF-36 subscales' scores were negatively correlated with the total score of MOSPM, three factor scores of MOSPM, and total scores of HAMD and HAMA; (3) PSPD patients with severe depression had significantly lower scores (p < .01) on SF-36 subscales' scores (except for GH subscale) and component summary scores as compared to PSPD patients with none or moderate depression; and (4) Multiple linear stepwise regression revealed that SF-36's physical component summary (PCS) subscale correlated with patients' age and MOSPM total score while SF-36's mental component summary (MCS) subscale correlated with total scores of HAMD and MOSPM total score. In sum, PSPD patients had a lower QoL as compared to general population. Pain, depression, and anxiety were significantly correlated with QoL of PSPD patients while age, pain, and depression were important factors influencing PCS and MCS.

When non-epileptic seizures fool the experts

Even when non-epileptic seizures are correctly diagnosed, appropriate treatment recommendations may not be fully or correctly implemented. We present a case of a 17-year-old girl with frequent non-epileptic seizures who presented for frequent trips to the emergency room (ER) and was admitted to an inpatient Child and Adolescent Psychiatric Facility. Despite being informed that episodes were non-epileptic seizures, various staff and healthcare providers at the psychiatric hospital continued to send the patient to the ER to treat suspected epileptic seizures. We discuss possible reasons why this may have occurred, including psychosocial and emotional reactions of staff members to the episodes. This discussion may also help to explain the persistence of the patient's episodes. We also present options for minimizing the potential for future mismanagement of non-epileptic seizures.

Diagnostic classifications in depression and somatization should include biomarkers, such as disorders in the tryptophan catabolite (TRYCAT) pathway

The tryptophan catabolite (TRYCAT) pathway is induced by indoleamine 2,3-dioxygenase (IDO), which upon activation depletes plasma tryptophan (TRP) and increases the synthesis of TRYCATs. Both phenomena are associated with somatization and depression. The aims of this study are to examine whether disorders in the TRYCAT pathway are specific to depression or somatization and whether the diagnoses somatization, depression, and comorbid depression+somatization reflect qualitatively distinct clinical and biological categories. Plasma TRP, the kynurenine (KY)/TRP and KY/kynurenic acid (KA) ratios were measured in 36 patients with somatization, 35 depressed and 38 depressed+somatization patients and 22 controls. Using pattern recognition methods, the diagnosis comorbid depression+somatization could not be validated, while there was an important overlap between depression and somatization, which form one continuum. Cluster analysis detected a) a control cluster; b) a cluster with lower tryptophan, and higher KY/TRP and KY/KA ratios and somatization scores; and c) a cluster with increased depression but lower KY/TRP values. The differences between both patient clusters were quantitative and not qualitative. Within the patient group, cluster analysis has generated a "pathway phenotype", i.e. aberrations in the TRYCAT pathway, which are associated with somatization rather than with depression.

A randomized double-blind clinical trial on analgesic efficacy of fluoxetine for persistent somatoform pain disorder

OBJECTIVES

To verify the efficacy and safety of fluoxetine in treating patients with persistent somatoform pain disorder (PSPD).

METHODS

In this 8-week, randomized double-blind placebo-controlled study, 80 patients with an ICD-10 diagnosis of PSPD were randomly assigned to receive 20mg fluoxetine or a placebo. Several psychological scales including Medical Outcomes Study Pain Measures (MOSPM), Hamilton Depression Scale-17 items (HAMD(17)) and Treatment Emergent Symptom Scale (TESS) were used to assess analgesic efficacy and safety of fluoxetine, and the possible analgesic mechanism of fluoxetine was preliminarily analyzed. All data were analyzed by SPSS11.5 with t-test, one-way ANOVA and a mixed-effects model repeated measures analysis. Intent-to-treat (ITT) analysis was performed and the last observation carry forward (LOCF) was used for missing values.

RESULTS

There was a significant difference of MOSPM total score between the fluoxetine and placebo group after 2 weeks of treatment. The analgesic effect of fluoxetine was related with treatment time, and depressive patients showed a better analgesic effect than non-depressive patients. An adverse effect of fluoxetine was scarcely found.

CONCLUSIONS

Fluoxetine has a better analgesic effect than a placebo in treating persistent somatoform pain disorder, and is considered a safe treatment; its analgesic effect may be related to an antidepressant effect.

Medically unexplained symptoms and somatoform disorders: diagnostic challenges to psychiatrists

BACKGROUND

Clinical limitations of the criteria of somatoform disorders (SDs) have been criticized. However, little objective evidence supports this notion. We aimed to examine the prevalence of SDs in a population with medically unexplained symptoms (MUS), which was expected to have higher probabilities meriting such diagnoses, and to evaluate factors that may influence the clinical judgment of psychiatrists.

METHODS

Data of subjects with MUS (n = 101, 9.5%) as their chief consulting problems, of 1,068 consecutive ethnic Chinese adult medical inpatients referred for consultation-liaison psychiatry services, were reviewed. Psychiatric diagnoses including SDs and clinical variables were collected. Those with SDs were followed-up 1 year later, and structured interviews were applied.

RESULTS

Patients with MUS had a high level of psychiatric comorbidity, especially depression (35.6%) and anxiety disorder (29.7%), rather than SDs (9.9%). Most diagnosed with SDs suffered from persistent MUS at the 1-year follow-up. Pain was the most common presentation of MUS. Most of the subjects diagnosed with SDs were female and younger, with multiple painful sites at presentation, no past psychiatric diagnosis and no comorbid organic diagnoses. The diagnosis of SDs was seldom given in those with simultaneous MUS and mood symptoms.

CONCLUSION

A significant proportion (9.5%) of patients in psychiatric consultation suffered from MUS, and most were comorbid with depression and anxiety. The identification of SDs was made in only 9.9%. Because MUS are associated with a high rate of mental comorbidities, psychiatric consultations while facing such clinical conditions are encouraged.

General medical and psychiatric perspectives on somatoform disorders: separated by an uncommon language

PURPOSE OF REVIEW

While Diagnostic and Statistical Manual of Mental Disorders-IV provided updated definitions and diagnostic criteria for the diagnoses subsumed under the category of somatoform disorders, various nosological questions are still unresolved. We assessed current research activity on important key concepts related to nosology, validity, and reliability of the Diagnostic and Statistical Manual of Mental Disorders-IV somatoform diagnoses.

RECENT FINDINGS

The initial Medline search for articles from 2000 through 2005 yielded a total of 912 articles. After checking for redundancy and excluding publications using other than Diagnostic and Statistical Manual of Mental Disorders-IV diagnostic criteria, a total of 101 articles was further reviewed. Heterogeneity of papers precluded statistical approaches; thus, a descriptive and narrative review was pursued.

SUMMARY

It appears that applying the specific categories and criteria as proposed by Diagnostic and Statistical Manual of Mental Disorders-IV only captures a small proportion of the phenomena of interest at the interface of medicine and psychiatry. A paradigm shift towards 'general medical/psychiatry interface disorders' in exchange for the current dichotomy of 'mind' vs. 'body' disorders, may reduce stigma associated with current diagnostic labeling, improve user acceptability, and stimulate research in this important but still fragmented clinical area that still lacks agreed-upon diagnostic definitions.

Somatoform disorders: the role of consultation liaison psychiatry

The somatoform disorders are encountered commonly in both primary and secondary care. Despite their high incidence, few hospitals have teams with the expertise to manage this group of conditions. The lack of appropriate carers leads to inappropriate care, including increased numbers of admissions and investigations, to the detriment of the patients. The absence of appropriate care also increases the cost to the health services. Multidisciplinary Consultation Liaison (C-L) Psychiatry teams operate within non-psychiatric settings and are dedicated to the mental health care of patients presenting in these areas. Their unique skills and approaches offer support and education to these non-psychiatric teams and care to this group of patients. They are thus ideally placed to assess, diagnose and manage individuals presenting with somatoform disorders. Unfortunately, these teams are not widely available, largely because the current climate within psychiatry leads services to concentrate on what is defined as serious mental illness, a term usually used synonymously with psychotic disorders, despite the large number of people suffering from somatoform disorders and the cost of their care. The dislike that some colleagues have for this group of conditions may further hamper the creation of these services. In order to provide efficient assessment of and treatment for individuals with somatoform disorders, C-L Psychiatry teams must be created to lead clinical development, research and training in this discipline. These teams will also lead on the further research required.

Insomnia in somatoform pain disorder: sleep laboratory studies on differences to controls and acute effects of trazodone, evaluated by the Somnolyzer 24 x 7 and the Siesta database

Patients with chronic pain often suffer from sleep disturbances, specifically decreased deep sleep, and thus may get into a vicious circle which maintains their pain condition. Utilizing polysomnography and psychometry, objective and subjective sleep and awakening quality was investigated in 11 patients with nonorganic insomnia (F51.0) related to somatoform pain disorder (SPD; F45.4) as compared with age- and sex-matched healthy controls of the Siesta normative database. Patients demonstrated a markedly deteriorated Pittsburgh Sleep Quality Index, a decreased Quality of Life Index, slightly increased self-reported anxiety (Zung SAS) and depression scores (Zung SDS), as well as an increased Epworth Sleepiness Scale and International Restless Legs Syndrome Scale score. Subjective sleep and awakening quality was markedly reduced, while somatic complaints were increased. Polysomnographic evaluation by a recently developed automatic sleep classifier (Somnolyzer 24 x 7) based on the rules of Rechtschaffen and Kales demonstrated reduced slow-wave sleep (SWS), the target variable in the present study, a decreased stage shift index, increased SWS latency and stage 4 sleep (S4) latency and an increased frequency of shifts from S2 to wakefulness (W) in patients as compared with controls. Minimal oxygen saturation was found decreased, periodic leg movements (PLMs) were increased. In the morning, patients showed deteriorated well-being, drive, mood and wakefulness. There were no significant noopsychic or psychophysiological differences between patients and controls (except for a reduced numerical memory and a slightly increased morning diastolic blood pressure in patients). Subsequent evaluation of the acute effects of 100 mg of a controlled-release formulation of trazodone (Trittico retard) in the patients demonstrated an increase in the target variable SWS, accompanied by a reduction in the number of awakenings and stage shifts. It normalized the frequency of shifts from S2 to W and reduced the frequency of shifts from W to S1, from S1 to S2, as well as from any stage to S1 and S2. Trazodone, however, also significantly reduced the total sleep period and S2 and increased the latency to S1. Moreover, the drug increased the reduced minimal O(2 )saturation, reduced the arousal index and the PLMs-in-wake index and normalized the increased morning diastolic blood pressure. In conclusion, our study demonstrated that SPD induced significant changes in subjective and objective sleep and awakening quality, which were partially mitigated by trazodone therapy. The data on the target variable SWS support our hypothesis of a key-lock principle in the diagnosis and drug treatment of sleep disorders. Our study provided the first evidence on the usefulness of the Somnolyzer 24 x 7 and the Siesta database in clinical practice.

Evidence for abnormal pain processing in fibromyalgia syndrome

OBJECTIVE

To review the pathophysiology of fibromyalgia syndrome.

DESIGN

Review of the literature available on Medline (1965-2001).

RESULTS

Fibromyalgia syndrome is a chronic pain syndrome that predominantly afflicts women. It is characterized by widespread pain, insomnia, fatigue, and the presence of multiple tender points. Despite intensifying research, the etiology of fibromyalgia has remained unclear. Importantly, neither infections, trauma, nor psychiatric abnormalities consistently precede the onset of pain in patients with this syndrome. There is, however, mounting evidence for central pain processing abnormalities in almost all fibromyalgia patients. These anomalies include hyperalgesia, allodynia, abnormal temporal summation of second pain, neuroendocrine abnormalities, and abnormal activation of pain-related brain regions.

CONCLUSIONS

Multiple abnormal findings in fibromyalgia patients strongly indicate a neuropathic pain syndrome, reminiscent of complex regional pain syndrome or postherpetic neuralgia. In addition, fibromyalgia syndrome seems to share similar characteristics with these neuropathic pain syndromes, including ineffective response to many analgesics.

Subjective body complaints as an indicator of somatization in elderly patients

The authors examined the correlation of subjective body complaints (measured by the Giessen Subjective Complaints List) with sociodemographic data, objective health measures, measures of subjective well-being, and clinicians' ratings of somatization and psychological impairment in 251 cognitively unimpaired general hospital inpatients aged >/=60 years. The level of subjective body complaints correlated most highly with self-assessed life satisfaction and age-related changes and with the clinicians' rating of somatization. The results suggest that the level of subjective body complaints is determined by subjective well-being rather than by objective health measures, and thus subjective body complaints may be an indicator of somatization in elderly inpatients.

A case of bilateral ptosis with unsteady gait: suggestibility and culture in conversion disorder

We report a case of a 14-year-old girl who presented, following a sudden onset, with bilateral ptosis, gait disturbance, difficulty swallowing and loss of appetite, right hypochondriacal pain, and frontal headache. Protracted neurological and medical examinations were unremarkable; neither was precipitating psychological stresses evident. The condition, which manifest as typical conversion disorder, lasted for one year. "Treatment" involving electrical stimulation of both eyes muscles and legs with positive reassurance resolved the symptom. This case supports the view that conversion disorder, not only involves a strong element of suggestion, but also incorporates socio-cultural sanctioned prescription.