Antidepressants and cognitive-behavioral therapy for symptom syndromes

Somatic symptoms are common in primary care and clinicians often prescribe antidepressants as adjunctive therapy. There are many possible reasons why this may work, including treating comorbid depression or anxiety, inhibition of ascending pain pathways, inhibition of prefrontal cortical areas that are responsible for "attention" to noxious stimuli, and the direct effects of the medications on the syndrome. There are good theoretical reasons why antidepressants with balanced norepinephrine and serotonin effects may be more effective than those that act predominantly on one pathway, though head-to-head comparisons are lacking. For the 11 painful syndromes review in this article, cognitive-behavioral therapy is most consistently demonstrated to be effective, with various antidepressants having more or less randomized controlled data supporting or refuting effectiveness. This article reviews the randomized controlled trial data for the use of antidepressant and cognitive-behavior therapy for 11 somatic syndromes: irritable bowel syndrome, chronic back pain, headache, fibromyalgia, chronic fatigue syndrome, tinnitus, menopausal symptoms, chronic facial pain, noncardiac chest pain, interstitial cystitis, and chronic pelvic pain. For some syndromes, the data for or against treatment effectiveness is relatively robust, for many, however, the data, one way or the other is scanty.     

Neuroanatomical correlates and somatosensorial disturbances in body dysmorphic disorder

Body dysmorphic disorder (BDD) is a condition characterized by an intense preoccupation with an imagined or slight defect in physical appearance. Although there is a general consensus that psychosocial factors play a major role in the development of BDD, there is some evidence suggesting that an organic somatosensorial disturbance may also exist in this condition. Several psychiatric and neurological disorders, including the interparietal syndrome, Gertsman's syndrome, inferoparietal syndrome, phantom limb syndrome, genital retraction syndrome, panencephalitis, cerebrovascular syndromes, and pharyngeal streptococcia affecting the basal ganglia, can present with somatosensorial disturbances similar to BDD. The cerebral pathology in all these disorders appears to be localized in the parietal-occipital region, indicating that cerebral involvement may also be associated with BDD. An interdependence exists between cerebral regions through integrated neural networks that enable efficient processing of information. Disturbances in these association pathways can lead to an imbalance in the extensive cerebral loops. Therefore, it is possible that a defect in information-processing may play a role in the pathogenesis of BDD.     

Cognitive rigidity in patients with depression and fibromyalgia

Background/ObjectiveThe comorbidity of depression and fibromyalgia chronic syndrome has been well documented in the literature; however, the cognitive structure of these patients has not been assessed. Previous results reported variability in cognitive rigidity in depressive patients, the key for this might be the presence of chronic physical pain such as fibromyalgia. The present study explores and compares the cognitive rigidity and differentiation, between patients with depression with and without fibromyalgia syndrome.MethodThirty one patients with depression and fibromyalgia were matched, considering age, sex and number of depressive episodes, with 31 patients with depression but without fibromyalgia diagnosis. Cognitive rigidity and differentiation were measured with the repertory grid technique.ResultsThe results indicated that depressed patients with fibromyalgia presented higher levels of depressive symptoms, greater cognitive rigidity and lower cognitive differentiation than those without fibromyalgia.ConclusionsThe results might inform future treatments to address the cognitive structure of these patients.     

Fluency disorders in genetic syndromes

The characteristics of various genetic syndromes have included “stuttering” as a primary symptom associated with that syndrome. Specifically, Down syndrome, fragile X syndrome, Prader-Willi syndrome, Tourette syndrome, Neurofibromatosis type I, and Turner syndrome all list “stuttering” as a characteristic of that syndrome. An extensive review of these syndromes indicated clients diagnosed with these syndromes do show evidence of nonfluency patterns, but not all would be considered stuttering. Many of the syndromes are marked by degrees of mental retardation that probably contribute to a higher than average prevalence of stuttering, as well as a higher than average prevalence of other fluency disorders (when compared to the population at large).

An in-depth analysis of the available data indicates that some of these genetic syndromes show patterns of stuttering that may be indicative of only that syndrome (or similar syndromes) that can be differentially diagnosed from developmental stuttering. Among these patterns are the word-final nonfluencies noted in Prader-Willi syndrome; the presence of stuttering in the absence of secondary behaviors noted in Prader-Willi syndrome and; the presence of palilalia, word-final and word-medial nonfluencies, and word-medial and word-final nonfluencies in Tourette syndrome. Implications for future research are discussed in light of these findings.

Educational objectives: The reader will be able to: (1) describe the various different genetic syndromes that are associated with fluency disorders; (2) describe the types of nonfluencies that are associated with the major types of genetic syndromes that have fluency disorders; (3) describe the behaviors that may assist in differentially diagnosing different types of speech characteristics associated with various genetic syndromes.     

Somatization,sensitization, and functional dyspepsia

Functional dysepsia (FD) is defined as persistent or recurrent pain or discomfort centered in the upper abdomen without evidence of organic disease likely to explain the symptoms. Visceral hypersensitivity, motor dysfunction, and impaired gastric accommodation are found in some patients with FD, and psychological factors like chronic stress, attention and perception bias are also likely to play a part in the symptom formation. There is considerable overlap of non-specific symptoms like fatigue, headache, abdominal discomfort, muscle pain, and sleep disturbance in patients with different functional disorders, in this article exemplified by FD, fibromyalgia, and chronic fatigue syndrome. This overlap of symptoms indicates a common underlying sensitization process, leading to somatization.     

The hypothalamo-pituitary-adrenal axis in chronic fatigue syndrome and fibromyalgia syndrome

The hypothalamo-pituitary-adrenal (HPA) axis plays a major role in the regulation of responses to stress. Human stress-related disorders such as chronic fatigue syndrome (CFS), fibromyalgia syndrome (FMS), chronic pelvic pain and post-traumatic stress disorder are characterized by alterations in HPA axis activity. However, the role of the HPA axis alterations in these stress-related disorders is not clear. Most studies have shown that the HPA axis is underactive in the stress-related disorders, but contradictory results have also been reported, which may be due to the patients selected for the study, the methods used for the investigation of the HPA axis, the stage of the syndrome when the tests have been done and the interpretation of the results. There is no structural abnormality in the endocrine organs which comprise the HPA axis, thus it seems that hypocortisolemia found in the patients with stress-related disorder is functional. It may be also an adaptive response of the body to chronic stress. In this review, tests used in the assessment of HPA axis function and the HPA axis alterations found in CFS and FMS are discussed in detail.     

Cognitive Factors in Fibromyalgia: The Role of Self-Concept and Identity Related Conflicts

Fibromyalgia is a syndrome characterized by the presence of diffuse and chronic musculoskeletal pain of unknown etiology. Clinical diagnosis and the merely palliative treatments considerably affect the patient's experience and the chronic course of the disease. Therefore, several authors have emphasized the need to explore issues related to self in these patients. The repertory grid technique (RGT), derived from personal construct theory, is a method designed to assess the patient's construction of self and others. A group of women with fibromyalgia (n = 30) and a control group (n = 30) were assessed using RGT. Women with fibromyalgia also completed the Fibromyalgia Impact Questionnaire and a visualanalogue scale for pain, and painful tender points were explored. Results suggest that these women had a higher present self-ideal self discrepancy and a lower perceived adequacy of others, and it was more likely to find implicative dilemmas among them compared to controls. These dilemmas are a type of cognitive conflict in which the symptom is construed as "enmeshed" with positive characteristics of the self. Finally, implications of these results for the psychological treatment of fibromyalgia are suggested to give a more central role to self-identity issues and to the related cognitive conflicts.     

Language phenotypes and intervention planning: bridging research and practice

This paper focuses on the communication and language phenotypes associated with three genetic disorders: Down syndrome, Williams syndrome, and fragile X syndrome. It is argued that there is empirical evidence that these disorders predispose children to specific profiles of strength and weakness in some areas of speech, language, and communication, and that intervention planning for children with each syndrome may take an approach informed by these profiles. Issues related to within-group variability, shared outcomes among syndromes, and the need for empirical validation for syndrome-specific recommendations are discussed.     

Chronic benign pain

Chronic benign pain (CBP) can be defined as a type of unpleasant sensory experience that arises from inflammation, visceral stress or damage, or other such pathophysiologic process(es), and that is not associated with a metastatic process. A patient's complaint of pain should be taken seriously by the practitioner, both in terms of the discomfort evoked and the likelihood that the potential cause of the pain requires diagnostic evaluation. This article reviews the diagnosis and treatment of the following common conditions associated with CBP syndromes: fibromyalgia, lower back pain syndrome, sickle-cell disease, reflex sympathetic dystrophy syndrome, and peripheral neuropathies.     

Cognitive Factors in Fibromyalgia: The Role of Self-Concept and Identity Related Conflicts

Fibromyalgia is a syndrome characterized by the presence of diffuse and chronic musculoskeletal pain of unknown etiology. Clinical diagnosis and the merely palliative treatments considerably affect the patient's experience and the chronic course of the disease. Therefore, several authors have emphasized the need to explore issues related to self in these patients. The repertory grid technique (RGT), derived from personal construct theory, is a method designed to assess the patient's construction of self and others. A group of women with fibromyalgia (n = 30) and a control group (n = 30) were assessed using RGT. Women with fibromyalgia also completed the Fibromyalgia Impact Questionnaire and a visual-analogue scale for pain, and painful tender points were explored. Results suggest that these women had a higher present self–ideal self discrepancy and a lower perceived adequacy of others, and it was more likely to find implicative dilemmas among them compared to controls. These dilemmas are a type of cognitive conflict in which the symptom is construed as “enmeshed” with positive characteristics of the self. Finally, implications of these results for the psychological treatment of fibromyalgia are suggested to give a more central role to self-identity issues and to the related cognitive conflicts.     

Multiaxial taxonomy of fibromyalgia syndrome patients

Pain, disability, and depression are present in various degrees in patients with fibromyalgia syndrome. Cluster analysis was used in this research to ascertain the existence of subgroups of patients in a fibromyalgia sample based on these variables. Two clusters were defined: one characterized by high levels of pain, disability, and depression (n=51) and another characterized by low levels of pain, disability, and depression (n=67). Multivariate analysis of variance (MANOVA) confirmed differences between clusters on these health status factors and a second MANOVA revealed that the subgroup with a poorer health status reported greater passive coping, helplessness, and stress, and less satisfaction with social support, than the subgroup with better health status. Logistic regression indicated that the best discriminator of subgroup membership was helplessness. These results suggest that different approaches to patient management, particularly intervention strategies aimed at reducing helplessness, may be beneficial for patients with high levels of pain, disability, and depression.     

Differential efficacy between cognitive-behavioral therapy and mindfulness-based therapies for chronic pain: Systematic review

Background/Objective: To assess the differential efficacy between mindfulness-based interventions and cognitive-behavioral Therapy (CBT) on chronic pain across medical conditions involving pain. Method: ProQuest, Science Direct, Google Scholar, Pubmed, and Embase databases were searched to identify randomized clinical trials. Measurements of mindfulness, pain, mood, and further miscellaneous measurements were included. Results: 18 studies met the inclusion criteria (fibromyalgia, n = 5; low back pain, n = 5; headache/migraine, n = 4; non-specific chronic pain, n = 4). In fibromyalgia, mindfulness based stress reduction (MBSR) was superior to the usual care and Fibroqol, in impact and symptoms. In low back pain, MBSR was superior to the usual care, but not to CBT, in physical functionality and pain intensity. There were no studies on differential efficacy between mindfulness and CBT for headache and non-specific chronic pain, but Mindfulness interventions were superior to the usual care in these syndromes. Conclusions: Mindfulness interventions are superior to usual cares in all diagnoses, but it is not possible to conclude their superiority over CBT. Comparisons between mindfulness interventions are scarce, with MBSR being the most studied. In central sensitization syndromes, variables associated with pain tend to improve with treatment. More research is needed to differentiate diagnosis and intervention.     

Biological and psychological factors associated with memory function in fibromyalgia syndrome.

Fibromyalgia is a stress-related disorder characterized by chronic pain, memory impairment, and neuroendocrine aberrations. With the hypothesis that biological and psychological symptoms may underlie the cognitive problems, the relative influences of neuroendocrine function and psychological factors on declarative memory were examined among 50 women with fibromyalgia. This within-group analysis controlled for age, education, pain, and relevant medications. Neuroendocrine function and depression had significant independent associations with memory function. Higher log-transformed mean salivary cortisol levels were associated with better performance on both immediate and delayed visual recall and with delayed verbal recall. Depressive symptoms were negatively associated with verbal recall. These findings suggest that a basic disorder of endocrine stress responses may contribute to the cognitive symptoms experienced by fibromyalgia patients.     

An integrated model of group psychotherapy for patients with fibromyalgia

This study examined the effectiveness of an integrated model of brief group psychotherapy for treatment of fibromyalgia syndrome, using cognitive behavioral and supportive expressive techniques. In the context of an outpatient, multidisciplinary fibromyalgia treatment program, group psychotherapy was provided to 35 patients with 21 control patients. Pre-post treatment measures of depression, anxiety, fibromyalgia impact, pain, fatigue, and morning tiredness were obtained. Using a quasi-experimental design with validated psychometric instruments, the results showed a significant decrease in pre-versus post treatment measures of depression, fibromyalgia impact, fatigue, and pain for the treatment patients, suggesting that an integrated model of group psychotherapy may have beneficial psychological and functional effects for some patients with fibromyalgia.     

The effects of emotional content on source monitoring in fibromyalgia patients

Source confusion refers to a person’s failure to distinguish whether an event has been actually seen or simply imagined. Nevertheless, prior research has demonstrated a reduction of source confusion for negative arousing information. According to the emotional-congruence effect, this emotional benefit is likely observed in patients suffering from chronic pain. This hypothesis was tested on 15 patients suffering of fibromyalgia syndrome (FMS) and 15 healthy women. In a source-monitoring task, participants had to decide whether positive, negative, and neutral words were imagined or seen with a picture. The results showed recognition deficits and more source confusion for FMS patients compared to controls. Contrary to the hypothesis of negativity bias in fibromyalgia, patients exhibited enhanced recognition for both positive and negative words. Moreover, they showed better source memory for the imagined items than for those seen with a picture. Overall, these results indicate that FMS affects episodic memory.     

Great Men: Psychoanalytic Studies by Edward Hitschmann. Foreword by Ernest Jones

Abstract

This study examined the effectiveness of an integrated model of brief group psychotherapy for treatment of fibromyalgia syndrome, using cognitive behavioral and supportive expressive techniques. In the context of an outpatient, multidisciplinary fibromyalgia treatment program, group psychotherapy was provided to 35 patients with 21 control patients. Pre–post treatment measures of depression, anxiety, fibromyalgia impact, pain, fatigue, and morning tiredness were obtained. Using a quasi–experimental design with validated psychometric instruments, the results showed a significant decrease in pre-versus post treatment measures of depression, fibromyalgia impact, fatigue, and pain for the treatment patients, suggesting that an integrated model of group psychotherapy may have beneficial psychological and functional effects for some patients with fibromyalgia.     

Reconceptualizing personality pathology in DSM-5: limitations in evidence for eliminating dependent personality disorder and other DSM-IV syndromes

The DSM-5 Personality and Personality Disorders Workgroup proposed that five DSM-IV personality disorders be eliminated as formal diagnostic categories (paranoid, schizoid, histrionic, narcissistic, and dependent), because these syndromes purportedly have low clinical utility and minimal evidence for validity. Scrutiny of studies cited in support of this proposal reveals difficulties in three areas: (1) Inadequate information regarding parameters of the literature search; (2) Mixed empirical support for proposed changes; and (3) Selective attention to certain disorders and not others. Review of validity and clinical utility data related to dependent personality disorder indicates that evidence regarding this syndrome does not differ from that of syndromes proposed for retention in DSM-5. Limitations in the research base cited by the workgroup illuminates gaps in the personality disorder literature, and may serve as a starting point for systematic research on personality pathology so that adequate empirical data are available to decide which syndromes to retain, revise, or remove in future versions of the diagnostic manual.     

An examination of the physical health, health care use, and psychological well-being of spouses of people with fibromyalgia syndrome.

The present study compared the physical and mental health and the health care use of spouses of patients with fibromyalgia syndrome (FS group; n = 135) with that of spouses of healthy individuals (n = 153). FS group participants reported lower health and affective states and scored higher on depression, loneliness, and subjective stress than comparison group participants (p < .017). Husbands in the FS group who reported more illness impact and whose wives reported worse sleep quality and less self-efficacy had more psychological difficulties. No differences were found in health care costs between groups. These findings suggest that chronic illness in a partner may negatively affect an individual's physical and mental health.     

Living with the unexplained: coping,distress, and depression among women with chronic fatigue syndrome and/or fibromyalgia compared to an autoimmune disorder

Chronic fatigue syndrome (CFS) and fibromyalgia are disabling conditions without objective diagnostic tests, clear-cut treatments, or established etiologies. Those with the disorders are viewed suspiciously, and claims of malingering are common, thus promoting further distress. It was hypothesized in the current study that levels of unsupportive social interactions and the coping styles used among those with CFS/fibromyalgia would be associated with perceived distress and depressive symptoms. Women with CFS/fibromyalgia (n = 39), in fact, reported higher depression scores, greater perceived distress and more frequent unsupportive relationships than healthy women (n = 55), whereas those with a chronic, but medically accepted illness comprising an autoimmune disorder (lupus erythematosus, multiple sclerosis, rheumatoid arthritis; n = 28), displayed intermediate scores. High problem-focused coping was associated with low levels of depression and perceived distress in those with an autoimmune condition. In contrast, although CFS/fibromyalgia was also accompanied by higher depression scores and higher perceived distress, this occurred irrespective of problem-focused coping. It is suggested that because the veracity of ambiguous illnesses is often questioned, this might represent a potent stressor in women with such illnesses, and even coping methods typically thought to be useful in other conditions, are not associated with diminished distress among those with CFS/fibromyalgia.     

An introduction to organic brain syndromes

Organic brain syndromes are of forensic interest for several reasons. First, patients with organic brain syndromes may require judicial determination of competence in any of a number of areas, e.g., testamentary capacity, need for financial guardianship, or competence to make medical decisions. Second, any patient whose mental state is of legal interest will need evaluation for contributing organic factors; uncovering these factors may have considerable medical and legal consequence. Third, the discovery of organic factors may be decisive in the outcome of a judicial proceeding, where “hard” biological data are often accorded more weight, and are thus more persuasive, than “soft” psychological data. This article provides an introductory overview of the organic brain syndromes. For each syndrome, the clinical features are described and are illustrated with a case vignette, the more common etiologies are presented, and selected aspects to the evaluation are highlighted. In addition, since the detectian of malingered mental illness is a key component in many forensic contexts, characteristics are described which help to distinguish actual from malingered mental illness.