Conscious and Preconscious Uses of Memory in Patients with Depressive and Somatoform Disorders

This study investigated whether conscious and preconscious memory features contribute to discrimination between depressive and somatoform disorders. Thirty-one participants fulfilling the diagnostic criteria for a somatoform disorder and 28 participants fulfilling the criteria for depression were examined within the framework of the process–dissociation paradigm using neutral, health-threatening, and general threatening words in a lexical decision task. Parameters of conscious memory, preconscious memory, and chance were used to compare memory features of both the groups. There was an inverse relationship between conscious and preconscious memory effects for health-threatening stimuli in the group of patients with somatoform disorders but not in the group of depressive patients. Patients with somatoform disorders showed a significantly lower level of conscious memory for health-threatening stimuli than depressive participants. Compared to depressive patients, a more dynamic relationship between decreased conscious and increased preconscious memory for health-related stimuli seems to be characteristic for patients with somatoform disorders.     

Idiopathic physical symptoms: a common manifestation of psychiatric disorders in primary care

Worldwide, patients with common mental disorders, such as depression and anxiety, have a tendency to present first to primary care exhibiting idiopathic physical symptoms. Typically, these symptoms consist of pain and other physical complaints that remain medically unexplained. While in the past, traditional psychopathology emphasized the relevance of somatic presentations for disorders, such as depression, in the last few decades, the "somatic component" has been neglected in the assessment and treatment of psychiatric patients. Medical specialties have come up with a variety of "fashionable" labels to characterize these patients and the new psychiatric nomenclatures, such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, attempt to classify these patients into a separate "somatoform disorders" category. These efforts fall short, and revisionists are asking altogether for the elimination of "somatoform disorders" from future nomenclatures. This review emphasizes the importance of idiopathic physical symptoms to the clinical phenomenology of many psychiatric disorders, offers suggestions to the diagnostic conundrum, and provides some hints for the proper assessment and management of patients with these common syndromes.     

Somatoforme Störungen und Bindungstheorie

Somatoform disorders are not only marked by somatic symptoms, but also by significant disturbances in interpersonal relationships. Interpersonal difficulties – including the maladaptive pattern of illness behavior and the resulting difficult doctor-patient-relationship – are an important field of therapeutic intervention (Nickel u. Egle 1999). The interpersonal problems which are characteristic in patients with somatoform disorders draw attention to the developmental aspects of these conditions. Attachment theory provides a promising framework for understanding these developmental features. In the paper presented we therefore apply concepts and observations from attachment theory to somatoform disorders. After a brief review of attachment theory we specifically discuss the developmental aspects of representation formation in somatization. As next, empirical evidence is reviewed that link attachment insecurity to the development of somatoform disorders. Finally a vulnerability model of somatoform disorders is outlined.     

Aus vier mach zwei

Background

The diagnostic and statistical manual of mental disorders 5 (DSM-5) includes a revision of the DSM-IV criteria for somatoform disorders. The aim of the current work was to investigate whether (a) patients with DSM-IV diagnoses of somatization disorder, pain disorder and hypochondriasis and (b) whether patients categorized as having the DSM-5 somatic symptom disorder and illness anxiety disorder differ with respect to illness anxiety and cognition regarding somatic symptoms.

Material and methods

The data from 269 inpatients from the psychosomatic clinic Schön Klinik Bad Bramstedt were used. Somatoform disorders were diagnosed using the German version of the structured clinical interview for DSM-IV (SCID).

Results

Patients with a DSM-IV diagnosis of hypochondriasis differed in illness anxiety and catastrophizing interpretation of somatic symptoms compared to patients with other somatoform disorders. Patients with illness anxiety disorder differed in the catastrophizing interpretation of physical symptoms, autonomic sensations, bodily weakness and intolerance of physical complaints compared to patients with somatic symptom disorder.

Conclusion

The present results indicate that illness anxiety and a catastrophizing interpretation of somatic symptoms play a fundamental role in patients with somatoform disorders. Therefore, psychotherapy should address illness anxiety and health-related concerns in all patients with somatoform disorders.     

Somatoforme Störungen

The therapy of somatoform disorders should focus on the reduction of physical symptoms. A constant improvement of these symptoms is not possible without the development of the body-self and the body-image, because serious somatoform disorders are always connected with problems of the self-structure, especially of the body-self and the body-image. A treatment approach is presented in a case study.     

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

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

Somatoforme Beschwerden bei Jugendlichen in Deutschland

As part of a larger survey involving a representative sample of 2.050 Germans aged 14 to 92 years, the prevalence of somatoform complaints among young people (N=189,14 to 25 years old) was analyzed separately.The instrument used was the SOMS 2 (Screening for somatoform disorders), a German questionnaire developed by Rief et al. (1997). It could be shown that somatoform complaints are less prevalent among young people, but still occur frequently.Most commonly mentioned were headaches, facial pain, backache, pains in the extremities, nausea and stomachache.Girls frequently mentioned menstrual pains.The socio-demographic variables “age” (14–19 vs. 20–25 yrs.),“gender” and “geographical region” (East vs.West Germany) proved to be unrelated to the prevalence of somatoform complaints in this age-group.By contrast to these findings on subjective complaints amongst young people, only one of the sample could be diagnosed as having a somatoform disorder in the sense defined by the DSM-IV or the ICD-10. This low rate of prevalence is the result of the extremely restrictive criteria defined for somatoform disorders by these diagnostic systems, which obscure the real frequency in the general population of somatoform syndromes requiring treatment.     

Proprioception in somatoform disorders

20 patients with somatoform disorders as defined by DSM-IV and 20 healthy controls were examined for their proprioception. Several psychophysiological theories of somatoform disorders suggest biased proprioceptive abilities. The primary question is, whether we may find an inaccurate myogen perception in somatization as suggested by the approach of Bischoff [Wahrnehmung der Muskelspannung (Perception of muscle tension) Gottingen: Hogrefe (1989)] or a more precise proprioception as may be derived from concepts of a higher awareness of body reactions [e.g. Barksky, A. J. (1992) Amplification, somatization, and the somatoform disorders. Psychosomatics, 39, 28–34; Salkovskis, P. M., & Clark, D. M. (1993) Panic disorder and hypochondiasis. Adv. Res. Ther. 15, 23–48]. Furthermore it is expected, that somatoform patients perceive their muscle tension more intensely than do healthy subjects. Proprioceptive abilities were tested using a visual EMG biofeedback task. Resulting objective data and subjective ratings were analyzed within a psychophysiological regression approach which allows one to estimate the reliability, precision and intensity of proprioception. Results revealed that somatoform subjects demonstrated a more precise but not a more intense perception of muscle tension than did healthy controls.     

Somatoform dissociation in eating-disordered patients

This study investigated the role of somatoform dissociation in eating disorders and pathological eating behaviour, relative to the established association of eating pathology with psychological dissociation. The participants were 131 women with DSM-IV diagnoses of anorexic or bulimic disorders and 75 women who had no such disorder. Each woman completed measures of psychological and somatoform dissociation, as well as a measure of bulimic attitudes. The current presence or absence of specific bulimic behaviours was identified during the clinical interview. Levels of both forms of dissociation were higher in the women who had diagnoses of disorders with a bulimic component (bulimia nervosa; anorexia nervosa of the binge/purge subtype) than in the non-clinical or restrictive anorexic women. Somatoform dissociation showed particularly strong links with the presence of bulimic behavioural features (excessive exercise, laxative abuse, diet pill abuse, diuretic abuse) and with bulimic attitudes. The formulation and treatment of cases where there are bulimic features is likely to be enhanced by the assessment of somatoform dissociation.     

Begutachtung von somatoformen Störungen

As a result of their prevalence somatoform disorders represent a substantial burden not only for health care systems but also for social security and pension programs around the world. In fact, in recent years there has been a steady increase in the number of applicants filing for disability pensions due to such disorders. Recent studies focus on the relationship between biological, psychological and social factors and the subjective experience of somatoform symptoms and their concomitant impairments. Despite this progress, diagnostic work in general remains a challenge. The purpose of this paper is first to discuss a dimensional diagnostic system for somatoform disorders. Secondly based on the dimensions of this diagnostic system, considerations regarding the differentiation of the diagnosis “pain disorder” will be made. Furthermore, considerations concerning the severity and prognosis of somatoform disorders are presented. These considerations should help to assess vocational disability.     

Einschränkungen der Willensfreiheit bei somatoformen Störungen

Etiopathogenetic models of somatoform disorders and philosophical concepts of free will refer to theories of affect processing: affective dysregulation can promote psychosomatic ailments as well as problems in decision making. This observation brings forth the question if freedom of will is impaired in persons with somatoform disorders. By compiling, analyzing and contextualizing relevant models of current neuroscience, psychosomatic medicine and philosophy the psychodynamic construct of alexithymia as an etiologic factor of somatoform disorders and the conceptual integration of affective factors in a model of free will are developed on the basis of a common concept of affect. The synthesis of the discussed results and considerations, the multidimensional impairment of the ability to decide freely and self-determinedly due to somatoform disorders, is critically reflected; however, a blanket assumption is not admissible.     

Actual neurosis as the underlying psychic structure of panic disorder, somatization, and somatoform disorder: an integration of Freudian and attachment perspectives

Starting from a contemporary critique of the DSM-IV, this paper argues that the diagnostic categories of panic disorder somatization, and undifferentiated somatoform disorders can be understood as belonging to a common type of psychopathology--i.e., the Freudian actual neuroses. In addition to their strong clinical similarity, these disorders share an etiological similarity; and the authors propose a combination of Freud's focus on this type of patient's inability to represent an endogenous drive arousal with the post-Freudian focus on separation anxiety. An etiological hypothesis is put forward based on contemporary psychoanalytic attachment theory, highlighting mentalization. Concrete implications for a psychoanalytically based treatment are proposed.     

Reliability of diagnosis in older psychiatric patients using the structured clinical interview for DSM-III-R

We conducted one of the few studies that has examined the reliability of the Structured Clinical Interview for DSM-III-R Axis I (SCID-I) with a mixed inpatient and outpatient population of adults 55 years old and over (range, 56–84 years; mean, 67.33 years). All SCID interviews were videotaped or audiotaped and were administered by Master's-level clinicians working toward their doctorate degrees in clinical psychology. Interrater reliability estimates (kappa and percentage agreement) were calculated for current major depressive episode (47% base rate) and the broad diagnostic categories of anxiety disorders (15% base rate) and somatoform disorders (12% base rate). Kappa values were .70, .77, and 1.0. Respective percentage agreement was 85% for major depression, 94% for anxiety disorders, and 100% for somatoform disorders. Overall percentage agreement was 91%. We conclude that the SCID-I can be effectively administered by relatively inexperienced clinicians to diagnose older psychiatric patients reliably. Directions that future research might take are offered.     

Is interoceptive awareness really altered in somatoform disorders? Testing competing theories with two paradigms of heartbeat perception

Alterations in the perception of body signals (i.e., interoceptive awareness [IA]) are considered crucial for the development and maintenance of somatoform disorders (SFDs). However, competing theories come to different conclusions about whether IA is increased or decreased in SFDs. The present study investigated IA in 23 patients with SFDs (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and in 27 healthy controls. IA was reliably assessed with two well-established heartbeat perception paradigms (heartbeat discrimination task and mental tracking task). The results of both paradigms showed no evidence for increased IA in patients with SFDs. Correlational analyses revealed that having a higher number of somatoform symptoms was significantly linked to lower (rather than higher) IA in SFDs. These findings are in line with recent cognitive approaches to SFDs that stress the importance of biased schema-guided processing of interoceptive information. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Affektverarbeitung und Beziehungsgestaltung bei somatoformen Störungen

Somatoform disorders are usually associated with disturbances in affective processing and consequently with relational disorders. The effect of psychotherapy on the emotional regulation and the relational behaviour in the course of treatment of a patient with somatoform autonomous dysfunction and dysthymia has been examined. Pre-post comparisons of inpatient treatment have been performed by means of standardized questionnaire data; the course of therapy has been evaluated by the analysis of the dependence of the leading symptom of hypogastric pain on mood parameters with the help of multivariate time-series analyses. One effect of psychotherapy was the initiation of an intrapsychic discourse, which led to an improved ability of affect regulation as well as to a better functioning in relationships. This was accompanied by a reduction of somatization. The interrelations between somatization, affect- and relationship-regulation are discussed.     

Tactile perceptual processes and their relationship to somatoform disorders

The Somatic Signal Detection Task (SSDT) is a recent paradigm serving to examine perceptual processes likely relevant for somatoform disorders. We tested whether touch illusions are more easily induced in individuals suffering from somatoform disorders (SFD) and whether their perceptual threshold for tactile stimuli is lower compared to healthy controls. Thirty-three participants with SFD and 32 healthy controls reported whether they recognized near-threshold tactile stimuli at their fingertip, which were presented in half of the test trials. With a probability of 0.5, an auxiliary visual stimulus was additionally presented. Tactile detection thresholds, tactile sensitivity, response bias, and the rate of false-positive perceptions of the tactile stimulus were assessed. In both groups, the light stimulus led to an amelioration of tactile sensitivity as well as to a more liberal response style. The SFD group was characterized by a more liberal response bias in the first half of the light-absent condition compared to the healthy controls. Within the SFD group, the report of somatoform (especially pseudoneurological) symptoms correlated positively with illusory tactile perceptions in the SSDT. Tactile thresholds in the SSDT were measured reliably (rtt = .86) and were significantly lower in the SFD group. The notion that general perceptual dispositions influence the formation of symptom perception may thus complement cognitive models of SFD.     

Beziehungs- oder Mentalisierungsfähigkeit

This paper investigates the predictive value of the psychological mindedness assessment procedure (PMAP) with respect to differential group therapy outcome using outpatient group therapies with patients suffering from somatoform disorders. Within the contextual framework of the mentalization theory the possible predictive power of the PMAP prior to indications for therapy is reflected. As the results of 50 patients from 6 therapy groups show high PMAP ratings prior to treatment onset predict group suitability of patients. This in turn is predictive for an emotional attunement of such patients during treatment, which is in itself a qualification for an emotional involvement with the group interactive process and therefore highly predictive. In contrast patients with a lower PMAP rating should be referred to groups where another treatment concept or technical attitude on the part of the group leader is realized. The shorter the therapy groups last the more homogeneous group composition should be regarding psychological functioning of patients prior to treatment onset (level of mentalization).     

Complexity of referrals to a specialist psychotherapy service

Consecutive referrals to a specialist psychotherapy service were analysed for complexity. Some 71% had a severe enduring mental illness or personality disorder. Two-thirds of the rest had added psychosocial or behavioural complexity. Only 9% had no severe enduring mental illness, personality disorder, or added complexity; nearly half of these had somatoform disorder. Only 2% of the patients had uncomplicated depression or anxiety disorders.

Patients treated in this psychotherapy service are substantially different from those on whom NICE bases its guidance for the treatment of depression and anxiety, and for whom IAPT was conceived, it functions as a de facto complex case service.     

Selective attention, memory bias, and symptom perception in idiopathic environmental intolerance and somatoform disorders

Idiopathic environmental intolerance (IEI) refers to a polysymptomatic condition, similar to somatoform disorders. Various processes seem to contribute to its yet unknown etiology. Attention and memory for somatic symptom and IEI-trigger words was compared among participants with IEI (n = 54), somatoform disorders (SFD; n = 44) and control participants (n = 54). Groups did not differ in a dot-probe task. However, in an emotional Stroop task, attention was biased in IEI and SFD groups toward symptom words but not toward IEI-trigger words. Only the IEI group rated trigger words as more unpleasant and more arousing, and participants remembered them better in a recognition task. These implicit and explicit cognitive abnormalities in IEI and SFD may maintain processes of somatosensory amplification.     

Personality disorders in patients with burning mouth syndrome

Burning Mouth Syndrome (BMS) presents high rates of comorbid Axis I disorders while no controlled studies have addressed the question of Axis II comorbidities. The aim of the present study was to examine DSM-IV (APA, 1994) Axis II comorbidity in BMS patients and to control for the specificity of this association. Seventy BMS patients were compared to a nonpsychiatric population sample and to patients with other Somatoform Disorders for the presence of personality disorders (assessed with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders [SCID-II; First, Gibbon, Spitzer, & Williams, 1997). Prevalence rates were compared using the Pearson's chi square test. At least one personality disorder (PD) was found in 85.7%, 24.3%, and 88.6% of subjects in the three groups, respectively. When examining PD subgroups, significant differences emerged even between the BMS and the somatoform disorder group, with BMS patients showing more Cluster A and fewer Cluster B PDs. Our results suggest that BMS is associated with a specific pattern of Axis II comorbidity.