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.     

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.     

An Integrative Approach to Somatoform Disorders Combining Interpersonal and Cognitive-behavioral Theory and Techniques

Data regarding the treatment of somatoform disorders suggest that the gains associated with current psychopharmacologic or psychotherapeutic treatments are modest at best. There have been a few moderately effective treatments for selected functional somatic syndromes, but patients who present with multi-system symptoms meeting criteria for the DSM-IV somatoform disorders are notoriously unresponsive to treatment. Experts in the field have advocated several approaches, including interpersonally oriented and cognitive-behavioral therapies, and have emphasized the importance of the provision of reassurance within the doctor-patient relationship. While each individual approach has merit, none is likely to be maximally efficacious as a stand-alone treatment. In this article we describe the theoretical underpinnings and technical aspects of a treatment for somatizing patients that integrates these three elements.     

A Unified,Transdiagnostic Treatment for Adolescents With Chronic Pain and Comorbid Anxiety and Depression

Chronic pain disorders represent a significant public health concern, particularly for children and adolescents. High rates of comorbid anxiety and unipolar mood disorders often complicate psychological interventions for chronic pain. Unified treatment approaches, based on emotion regulation skills, are applicable to a broad range of emotional disorders and suggest the possibility of extending these interventions to chronic pain and pain-related dysfunction. This case report describes the use of a unified protocol for treatment of an adolescent boy with chronic daily headache and social anxiety and an adolescent girl with whole body pain and depression. Following weekly, 50-minute individual treatment sessions, the boy demonstrated notable improvement in emotional symptoms, emotion regulation skills, somatization, and functional disability. The girl showed some improvement on measures of anxiety and depression, although there appeared to be a worsening of pain symptoms and somatization. However, both patients demonstrated improvement over follow-up. This case study illustrates the potential utility of a unified treatment approach targeting pain and emotional symptoms from an emotion regulation perspective in an adolescent population.     

心身障碍共病与慢性疼痛关联的结构模型

常见的心身障碍共病可以理解为一种新的精神疾病结构模型：情绪障碍、抑郁、焦虑及躯体化障碍等归为内化性疾病谱系的组成元素,物质滥用和反社会行为障碍归为外化性疾病谱系的组成元素。本文分析探讨评估慢性疼痛与这一模型的联系。社会心理和生物学的研究证据表明慢性疼痛与内化性障碍密切相关,提示内化-外化性疾病模型可以作为一个有效的研究架构,为探讨慢性疼痛与情感、抑郁焦虑及其他相关精神障碍的关联共病机制提供新的研究方向和新思路。     

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.     

To be sure, to be sure: intolerance of uncertainty mediates symptoms of various anxiety disorders and depression

The Intolerance of Uncertainty Model was initially developed as an explanation for worry within the context of generalized anxiety disorder. However, recent research has identified intolerance of uncertainty (IU) as a possible transdiagnostic maintaining factor across the anxiety disorders and depression. The aim of this study was to determine whether IU mediated the relationship between neuroticism and symptoms related to various anxiety disorders and depression in a treatment-seeking sample (N=328). Consistent with previous research, IU was significantly associated with neuroticism as well as with symptoms of social phobia, panic disorder and agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, and depression. Moreover, IU explained unique variance in these symptom measures when controlling for neuroticism. Mediational analyses showed that IU was a significant partial mediator between neuroticism and all symptom measures, even when controlling for symptoms of other disorders. More specifically, anxiety in anticipation of future uncertainty (prospective anxiety) partially mediated the relationship between neuroticism and symptoms of generalized anxiety disorder (i.e. worry) and obsessive-compulsive disorder, whereas inaction in the face of uncertainty (inhibitory anxiety) partially mediated the relationship between neuroticism and symptoms of social anxiety, panic disorder and agoraphobia, and depression. Sobel's test demonstrated that all hypothesized meditational pathways were associated with significant indirect effects, although the mediation effect was stronger for worry than other symptoms. Potential implications of these findings for the treatment of anxiety disorders and depression are discussed.     

Somatic symptom reporting has a dimensional latent structure: Results from taxometric analyses

Medically unexplained symptoms (MUS) are one of the key features of somatoform disorders. Although MUS are currently treated as both categorical (in terms of the diagnosis of somatoform disorders) and dimensional (in terms of quantitative measures of somatization/somatic symptom reporting), little is known about the empirical latent structure of MUS. Using taxometric analyses, the latent structure of somatic symptom reporting was analyzed with the Patient Health Questionnaire (PHQ)-15 in two student samples (N = 782 and N = 2,577) and a primary care sample (N = 519). We applied three popular taxometric methods: Maximum Eigenvalue (MAXEIG), Mean Above Minus Below a Cut (MAMBAC) and Latent-Mode (L-Mode). Simulation data were created to evaluate the appropriateness of the data for our analyses and to create the comparison curve fit index (CCFI) as an objective outcome measure. The results of all taxometric methods in any of the three data sets were in favor of a dimensional solution (CCFI < .50). Simulated taxonic and dimensional datasets differed substantially and the samples were appropriate for taxometric analysis. Accordingly, the latent structure of somatization/somatic symptom reporting as assessed by the PHQ-15 is dimensional in both primary care and student samples. Implications regarding the practical application as well as models of etiology and pathogenesis of somatic symptom reporting are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Symptom Expression and Somatization Among Elderly Korean Immigrants

In a study of expression of symptoms of somatization, depression, and other biopsychological conditions, 70 elderly Korean immigrants in the greater Washington, D.C., metropolitan area (35 who met the criteria for major depression and 35 who did not meet those criteria) were administered a Korean version of the Brief Symptom Inventory (BSI). Subjects who met the criteria for depression had the highest mean score on the BSI somatization dimension compared with other normative samples including a sample of psychiatric inpatients. A factor analysis of data from the BSI showed that for elderly Korean immigrants, a factor of somatization was identified that included the items from the original BSI obsessive-compulsive, somatization, and anxiety dimensions. Items loading on the somatization factor suggest that elderly Korean subjects experience body and mind as a unitary system and tend to communicate the distress associated with old age, cultural adjustment, and family and social changes through somatic symptoms.     

Somatic complaints in anxious children

Although stomachaches and headaches are considered characteristic of children with anxiety disorders, there is converging evidence that a broader range of somatic symptoms may be associated with children's expressions of anxiety. The purpose of this study was to determine the prevalence of somatic complaints in anxious children. The results indicated that children with anxiety disorders endorsed the presence of many different somatic complaints, and that contrary to clinical intuition, stomaches and headaches were not among the most commonly reported symptoms. In addition, the anxious children endorsed significantly more somatic complaints when compared to normal controls. Furthermore, the symptom pattern reported by anxious children indicated the presence of both the somatic and cognitive components usually associated with panic attacks, although none of the children met diagnostic criteria for panic disorder. The results are discussed in terms of the contribution of somatic symptoms to the understanding of anxiety disorders in children.     

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.     

Evaluating the Unified Protocol in the Treatment of Dissociative Identify Disorder

The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP; Barlow, Allen, & Choate, 2004) is a transdiagnostic cognitive behavior therapy for emotional disorders that addresses mood, anxiety, somatoform, and borderline personality disorders. Patients diagnosed with dissociative identity disorder (DID) form a nontrivial subset of patients. Extant treatment guidelines (ISSTD, 2011) emphasize the need to strive for fusion of identities (i.e., the creation of a unified sense of self). In contrast, the UP strives to inculcate an array of adaptive emotion skills, including cognitive reappraisal, emotional awareness, and affect tolerance, prior to planned exposure to traumatic memories. In this study, we provide the first assessment of the effectiveness of the UP with 5 individuals diagnosed with DID and co-occurring disorders and symptoms tracked at multiple time points. After 18–22 sessions, 4 patients exhibited significant reductions in anxiety, depression, and dissociative symptoms, and increases in emotional regulation, with significant improvements in symptomatology maintained after follow-ups of 1, 3, and 6 months. A fifth participant with prominent suicidal ideation was treated for 42 sessions and achieved comparable reductions in symptoms. None of the patients met criteria for DID or any other disorder at 6-month follow-up.     

Hypochondriasis Among Patients with Multiple Somatoform Symptoms—Psychopathology and Outcome of a Cognitive-Behavioral Therapy

As hypochondriasis often occurs with somatization, patients with somatization disorder plus hypochondriasis were compared to patients with somatization syndrome alone regarding psychopathology, patterns of physical symptoms and outcome of a cognitive-behavioral inpatient treatment. A sample of patients with DSM-IV hypochondriasis and multiple somatoform symptoms(N = 27) and a matched sample of patients with multiple somatoform symptoms but without hypochondriasis (N = 27) were assessed. All subjects obtained a cognitive-behavioral treatment for somatization and hypochondriasis. Assessment took place at admission and at one-year follow-up. Only a few differences between the groups were found: Hypochondriacs suffered more often from abdominal pain, and they reported a higher intolerance of bodily complaints. At follow-up, all outcome variables improved significantly. High effect sizes were found for the reduction of symptoms and the mean number of visits to the doctor. The specific effect on health care use highlights the socioeconomic relevance of these results.     

Construct validity of the Anxiety Sensitivity Index-3 in clinical samples

Using two clinical samples of patients, the presented studies examined the construct validity of the recently revised Anxiety Sensitivity Index-3 (ASI-3). Confirmatory factor analyses established a clear three-factor structure that corresponds to the postulated subdivision of the construct into correlated somatic, social, and cognitive components. Participants with different primary clinical diagnoses differed from each other on the ASI-3 subscales in theoretically meaningful ways. Specifically, the ASI-3 successfully discriminated patients with anxiety disorders from patients with nonanxiety disorders. Moreover, patients with panic disorder or agoraphobia manifested more somatic concerns than patients with other anxiety disorders and patients with nonanxiety disorders. Finally, correlations of the ASI-3 scales with other measures of clinical symptoms and negative affect substantiated convergent and discriminant validity. Substantial positive correlations were found between the ASI-3 Somatic Concerns and body vigilance, between Social Concerns and fear of negative evaluation and socially inhibited behavior, and between Cognitive Concerns and depression symptoms, anxiety, fear of negative evaluation, and subjective complaints. Moreover, Social Concerns correlated negatively with dominant and intrusive behavior. Results are discussed with respect to the contribution of the ASI-3 to the assessment of anxiety-related disorders.     

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.     

Socio-demographic conditions, subjective somatic health, Axis I disorders and personality disorders in the common population: the relationship to quality of life

Quality of life (QOL) was studied in a population of 2,065 subjects in Norway. A broad concept of QOL was applied, including subjective well-being, self-realization, negative life events, and a number of interpersonal relationships. The assessment of QOL, based on interview, was related to a number of socio-demographic variables, subjectively experienced somatic health, the most common Axis I disorders, and all Axis II personality disorders (PDs). The results of multivariate analyses showed that being female and living with a partner in the outskirts of a city and having good physical health are important positive correlates of QOL. Controlling for all these variables, major depression, dysthymic disorder, and somatoform disorders were the Axis I disorders that have a negative statistical effect on global QOL. Specific anxiety disorders did not add to the effects. Among the PDs, avoidant, schizotypal, paranoid, and schizoid PD traits were the most important statistical negative determinants of QOL, followed by borderline, dependent, antisocial, and also self-defeating and narcissistic PDs, restricted to some specific sub-indexes of QOL. The study also showed that our results vary and are sometimes the opposite, depending on the sub-index of QOL examined. The study showed that it is necessary to apply a broad concept of QOL to disclose the real nature or the relationship between mental disorders and QOL. Furthermore, demographic variables, subjectively experienced somatic health, Axis I disorders, and PD traits appeared to be independently associated with QOL.     

Similarities Between the Psychological Profiles of Complex Regional Pain Syndrome and Conversion Disorder Patients

The psychological profile of 17 Complex Regional Pain Syndrome type I (CRPS) and 20 Conversion Disorder (CD) patients were compared, using the Minnesota Multiphasic Personality Inventory (MMPI) and standardized, semistructured psychological interviews. Both groups presented abnormally high somatization scores. Low anxiety scores in both groups indicate that somatization may have served as a defense mechanism to bind anxiety. Depression was apparent in both groups, indicating that psychological distress accompany these syndromes. About one third of the participants in both groups presented comorbid Axis I disorders, mostly depression and PTSD. CRPS patients have traditionally been looked upon as suffering from mainly organic symptoms, whereas CD patients have been labeled as psychiatric patients. These results may indicate the need to reexamine the traditional classifications in respect to disorders that involve body and mind.     

The role of defeat and entrapment in depression, anxiety, and suicide

Defeat and entrapment are psychological constructs that have played a central role in evolutionary accounts of depression. These concepts have since been implicated in theoretical accounts of anxiety disorders and suicidality. The current article reports on a systematic review of the existing research investigating the links among defeat, entrapment, and psychopathology in the domains of depression, suicidality, posttraumatic stress disorder (PTSD), and other anxiety syndromes. Fifty-one original research articles were identified and critically reviewed. There was strong convergent evidence for a link with depressive symptoms, across a variety of clinical and nonclinical samples. Preliminary support for an association with suicidality was also observed, with effects not readily explainable in terms of comorbid depression. There was strong evidence for an association between defeat and PTSD, although this may have been partly accounted for by comorbid depression. The findings for other anxiety disorders were less consistent. There was, however, evidence that social anxiety in individuals with psychosis may be related to perceptions of entrapment. Overall, there was evidence that perceptions of defeat and entrapment were closely associated with various forms of human psychopathology. These effects were often in the moderate to large range and superseded the impact of other environmental and psychological stressors on psychopathology. We provide a unified theoretical model of how defeat and entrapment may contribute to these different psychopathological conditions. Clinical implications and avenues for future research are discussed.     

Thought-action fusion and anxiety disorders symptoms in normal adolescents.

The present study examined thought-action fusion (TAF) in a large sample of normal adolescents (n=427). Participants completed the Thought-Action Fusion Questionnaire for Adolescents (TAFQ-A) and scales measuring trait anxiety, symptoms of obsessive-compulsive disorder, other anxiety disorders, and depression. Results showed that the TAFQ-A is a reliable instrument assessing two dimensions of TAF, viz. Morality (i.e., the belief that unacceptable thoughts are morally equivalent to overt actions) and Likelihood (i.e., the belief that thinking of an unacceptable or disturbing situation will increase the probability that that situation actually occurs). Furthermore, TAF was not only associated with symptoms of OCD, but also with symptoms of other anxiety disorders and depression. However, when controlling for levels of trait anxiety, most connections between TAF and anxiety disorders symptoms disappeared. Symptoms of OCD and generalised anxiety remained significantly related to TAF. Altogether, the data are supportive of the notion that TAF is involved in a broad range of anxiety disorders and in particular OCD.