Body image in patients with somatoform disorder

Integrated care model for patients with functional somatic symptom disorder - a co-produced stakeholder exploration with recommendations for best practice

BACKGROUND

Functional somatic symptoms (FFS) and bodily distress disorders are highly prevalent across all medical settings. Services for these patients are dispersed across the health care system with minimal conceptual and operational integration, and patients do not currently access therapeutic offers in significant numbers due to a mismatch between their and professionals' understanding of the nature of the symptoms. New service models are urgently needed to address patients' needs and to align with advances in aetiological evidence and diagnostic classification systems to overcome the body-mind dichotomy.

METHOD

A panel of clinical experts from different clinical services involved in providing aspects of health care for patients with functional symptoms reviewed the current care provision. This review and the results from a focus group exploration of patients with lived experience of functional symptoms were explored by the multidisciplinary expert group, and the conclusions are summarised as recommendations for best practice.

RESULTS

The mapping exercise and multidisciplinary expert consultation revealed five themes for service improvement and pathway development: time/access, communication, barrier-free care, choice and governance. Service users identified four meta-themes for best practice recommendations: focus on healthcare professional communication and listening skills as well as professional attributes and knowledge base to help patients being both believed and understood in order to accept their condition; systemic and care pathway issues such as stronger emphasis on primary care as the first point of contact for patients, resources to reduce the length of the patient journey from initial assessment to diagnosis and treatment.

CONCLUSION

We propose a novel, integrated care pathway for patients with 'functional somatic disorder', which delivers care according to and working with patients' explanatory beliefs. The therapeutic model should operate based upon an understanding of the embodied nature of patient's complaints and provide flexible access points to the care pathway.

Picturing disturbed body experience: A comparison of body drawings in persons with somatoform disorder and a general population sample

People with somatic symptom disorder or somatoform disorder are considered to have a troubled relationship to their body that is hard to assess with self-report questionnaires alone. To examine the potential value of own-body drawings as an assessment tool, objective features of drawings from 179 patients referred to treatment for somatoform disorder, were compared to those of 173 age-and-sex matched persons from the general population. While two factors had been found in the somatoform disorder sample, in the general population only the factor that reflected 'details' in own-body drawings was replicated. The two samples did not score differently on this factor. The general population sample showed a less strong association between objective body drawings scores on this 'details' factor and self-reported scores of body experience than the somatoform disorder sample. Moreover, the phenomenological contents of the drawings were more oriented towards health or appearance than the mostly mixed or unclear orientation of persons with somatoform disorder. Because the objective scoring of body drawings did not differ between groups while the contents of body drawings appeared to differ, the results suggest that this objective scoring of body drawings is not appropriate to distinguish people with and without somatoform disorder.

[A Short Version of the Body Experience Questionnaire (FBeK): Results of Clinical and Non-Clinical Samples]

OBJECTIVES

The aim of this study was the development and evaluation of a short (9-item) version of the body experience questionnaire (FBeK-9).

METHOD

Based upon a representative survey from 1996, a 15-item version of the FBeK was constructed which was then evaluated in another representative sample (n=2510) as well as three clinical groups, namely patients with depressive disorders (n=106), patients with eating disorders (N=107), and patients suffering from pain (N=90). Depressive and anxiety symptoms and pain disability (PHQ-9, PHQ-4, PDI) were also assessed. Item selection and the determination of the factor structure were performed using exploratory and confirmatory factor analysis and led to the development of the FBeK-9. The final three subscales were tested for invariance related to sex, age and disorder. In addition, convergent validity was assessed and norms were provided.

RESULTS

Models of confirmatory factor analyses revealed acceptable fit indices ((CFI) =0.982,(ω ) =0.020) in all samples. The subscales "uncertainty/impaired sensation","attractiveness/self-confidence" and "accentuation of the body/sensitivity" indicated acceptable reliability (ω=0.707) and correlated with depressive and anxiety symptoms and pain in an expected manner. We also could show differences between the normative sample and the clinical groups. Measurement invariance was shown for age and sex.

CONCLUSIONS

It can be concluded that the 9-item version of the body experience questionnaire also provides a reliable, valid and economically efficient measure that can be used in studies of body experience in non-clinical and clinical samples. In the future, more validity studies should be performed.

Development of the Body-Relatedness Observation Scale: A feasibility study

BACKGROUND

One characteristic of somatoform (DSM-IV) and somatic symptom disorder (DSM-5) is the troubled relation of patients to their body. To assess body-relatedness, standardized observation by a physical therapist may add valuable information to questionnaires. Purpose: This study examines the feasibility of a physiotherapeutic observation instrument: the Body-Relatedness Observation Scale (BROS). Methods: Factorial validity and inter-rater reliability of observer scores were studied in 191 patients performing two short exercises, lying face up. Fourteen indicators of body-relatedness were selected, covering execution of instructions, perception of the body, muscle tension, and behavioral adaptation to somatic symptoms. Results: Inter-rater reliability values (Kappa or Intraclass correlation [ICC] according to model 1,1) were excellent for four observation scores, substantial for two, fair for two, and poor for six. Four out of five items relating to patients' ability to perceive the body had low inter-rater reliability values (ICC < 0.40 or Kappa < 0.20). Categorical principal components analysis with the eight reliable scores indicated a 1-factor structure including seven items with Cronbach's alpha 0.69. Conclusion: This initial analysis of a structured physical therapeutic observation for people with somatic symptom disorder indicated modestly sound psychometric quality of observations of execution of instructions, muscle tension, and behavioral adaptation, but not of patients' ability to perceive the body adequately. This shows that body-related observations are feasible and indicates the viability of further development of the BROS.

Body Image in Patients with Marfan Syndrome

This study aimed to assess body image impairments of individuals with Marfan syndrome and to determine to what extent psychological, physical, and sociodemographic factors influence body image. We assessed the physical fitness and psychosocial health of 42 patients with Marfan syndrome at the beginning of an inpatient rehabilitation program. All participants filled out a body image questionnaire consisting of two scales: (1) Negative Body Evaluation and (2) Vital Body Dynamics. We compared body image data of the study sample with the German representative norming sample and carried out two separate regression analyses in order to determine which variables were associated with the two dimensions of patients' body image. Body image of individuals with Marfan syndrome appeared to be significantly impaired, with high percentile ranks for Negative Body Evaluation (women = 88, men = 91) and low percentile ranks for Vital Body Dynamics (women = 11, men = 4). Vital Body Dynamics was predicted by age (p = 0.016) and by depression (p < 0.001), and Negative Body Evaluation was predicted by anxiety (p = 0.001). Body image in individuals with Marfan syndrome is not primarily determined by objective measures of fitness or by objective cardiac impairment but by psychological variables like depression and anxiety and by age. This finding can inform treatment and rehabilitation concepts. Accepting Marfan syndrome, including the acceptance of being visually different, may not only demand medical treatment and physical rehabilitation but also psychological treatment for depression and anxiety.