Somatic Symptom Disorder and Health Anxiety: Assessment and Management

Comparative analysis of emotional factors in patients with somatic symptom disorder and panic disorder

OBJECTIVE

This study investigated the emotional symptom profiles and treatment responses in patients exhibiting overlapping physical symptoms to compare differences between Somatic Symptom Disorder (SSD) and Panic Disorder (PD).

METHODS

Pharmacotherapy outcomes were analysed in 208 outpatients with SSD (n = 94) and PD (n = 114). Stepwise multivariable logistic regression identified predictors of treatment response, considering variables such as the Clinical Global Impression-Severity (CGI-S), Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory, and State-Trait Anger Expression Inventory. Network analysis explored emotional patterns by estimating network structures for each group.

RESULTS

The overall response rate to pharmacotherapy was 23.6% (49/208), with no significant difference between groups. Baseline CGI-S and BDI-II scores were significant predictors of treatment response in both groups, while social phobia score was a significant predictor in PD. Depression and anxiety were related to physical symptoms in both groups, but anger was significantly associated only in SSD. Network analysis revealed that depression was central to other symptoms in SSD, while anxiety was the core symptom in PD, indicating different emotional drivers between the disorders.

CONCLUSIONS

This study suggests the differences in emotional symptom profiles between SSD and PD. Findings suggest different mechanisms, considering the role of anger in SSD, highlighting the need for more personalised treatments for each disorder.

A case report of ineffective electroconvulsive therapy for chronic pain

Background

Somatic symptom disorder (SSD), which includes chronic pain, is a common mental disorder characterized by significant functional impairment and other psychiatric comorbidities. Electroconvulsive therapy (ECT) has been proposed as a potential treatment for refractory chronic pain. However, evidence supporting its efficacy is limited and/or low quality. We present a case of SSD with chronic pain in which ECT was ineffective.

Case Presentation

The patient was a 63-year-old man with chronic pain in the lower back, buttocks, thighs, and soles of the feet. The duration of his chronic pain was 3.8 years. He was diagnosed with Bertolotti's syndrome and SSD. He did not meet the criteria for major depressive disorder. He kept physically active by walking and doing exercises to distract himself from his pain. He strongly perceived pain as a physical issue and preferred ECT over psychotherapy. Despite undergoing 10 ECT sessions with adequate seizures, his pain persisted. After four sessions, he experienced despair over the lack of improvement in pain, which temporarily intensified his suicidal ideation. After undergoing ECT, he continued to maintain his activities, including walking and exercise, while his catastrophic thinking about pain persisted.

Conclusion

The ineffectiveness of ECT in this case highlights the need for balanced counseling, particularly for patients who consider ECT a last-resort treatment. Psychological monitoring and depression screening are essential, especially given the risk of heightened despair or suicidal ideation when ECT is ineffective. Therefore, collaborative decision-making based on accurate information is vital.

Neuroscience in pictures: Functional neurological disorder

Functional neurological disorder (FND) is a biopsychosocially-complex, prevalent, and potentially disabling neuropsychiatric condition. In this pictorial review, we explore the complexity of FND, from its diagnosis and conceptualization to current mechanistic understandings. We highlight advances in neuroimaging research that have revealed structural and functional brain alterations in FND and discuss a variety of factors that may serve as predisposing vulnerabilities for the development of this condition and/or perpetuate symptoms. This overview is designed as an initial teaching resource to educate trainees, clinicians, and researchers, highlighting core concepts in the literature on FND. Given that mechanistic research in FND is at a relatively early stage and is rapidly evolving, the interested reader should aim to continue updating their mechanistic understanding of FND as research further advances in this area.

Global research status and trends of somatic symptom disorder: A bibliometric study

BACKGROUND

With the growing scholarly and clinical fascination with somatic symptom disorder (SSD), a bibliometric analysis is lacking.

AIM

To conduct a bibliometric analysis to investigate the current status and frontiers of SSD.

METHODS

The documents related to SSD are obtained from the web of science core collection database (WoSCC), and VOSviewer 1.6.16 from January 1, 2000 to December 31, 2023, and the WoSCC's literature analysis wire were used to conduct the bibliometric analysis.

RESULTS

A total of 567 documents related to SSD were included, and 2325 authors across 947 institutions from 57 countries/regions have contributed to SSD research, published in 277 journals. The most productive author, institution, country and journal were Löwe B, University of Hamburg, Germany, and Journal of Psychosomatic Research respectively. The first high-cited document was published in the Journal of Psychosomatic Research in 2013 by Dimsdale JE and colleagues, which explored the rationale behind the SSD diagnosis introduction in diagnostic and statistical manual of mental disorders.

CONCLUSION

In conclusion, the main research hotspots and frontiers in the field of SSD are validity and reliability of the SSD criteria, functional impairment of SSD, and the treatment for SSD. More high-quality studies are needed to assess the diagnosis and treatment of SSD.

Biomarkers and Rehabilitation for Functional Neurological Disorder

Functional neurological disorder, or FND, is widely misunderstood, particularly when considering recent research indicating that the illness has numerous biological markers in addition to its psychiatric disorder associations. Nonetheless, the long-held view that FND is a mental illness without a biological basis, or even a contrived (malingered) illness, remains pervasive both in current medical care and general society. This is because FND involves intermittent disability that rapidly and involuntarily alternates with improved neurological control. This has in turn caused shaming, perceived low self-efficacy, and social isolation for the patients. Until now, biomarker reviews for FND tended not to examine the features that are shared with canonical neurological disorders. This review, in contrast, examines current research on FND biomarkers, and in particular their overlap with canonical neurological disorders, along with the encouraging outcomes for numerous physical rehabilitation trials for FND. These findings support the perspective endorsed here that FND is unquestionably a neurological disorder that is also associated with many biological markers that lie outside of the central nervous system. These results suggest that FND entails multiple biological abnormalities that are widely distributed in the body. General healthcare providers would benefit their care for their patients through their improved understanding of the illness and recourses for support and treatment that are provided in this review.

Mechanistic studies in pathological health anxiety: A systematic review and emerging conceptual framework

BACKGROUND

Pathological health anxiety (PHA) (e.g., hypochondriasis and illness anxiety disorder) is common in medical settings and associated with increased healthcare costs. However, the psychological and neurobiological mechanisms contributing to the development and maintenance of PHA are incompletely understood.

METHODS

We performed a systematic review to characterize the mechanistic understanding of PHA. PubMed, PsycINFO, and Embase databases were searched to find articles published between 1/1/1990 and 12/31/2022 employing a behavioral task and/or physiological measures in individuals with hypochondriasis, illness anxiety disorder, and PHA more broadly.

RESULTS

Out of 9141 records identified, fifty-seven met inclusion criteria. Article quality varied substantially across studies, and was overall inadequate. Cognitive, behavioral, and affective findings implicated in PHA included health-related attentional and memory recall biases, a narrow health concept, threat confirming thought patterns, use of safety-seeking behaviors, and biased explicit and implicit affective processing of health-related information among other observations. There is initial evidence supporting a potential overestimation of interoceptive stimuli in those with PHA. Neuroendocrine, electrophysiology, and brain imaging research in PHA are particularly in their early stages.

LIMITATIONS

Included articles evaluated PHA categorically, suggesting that sub-threshold and dimensional health anxiety considerations are not contextualized.

CONCLUSIONS

Within an integrated cognitive-behavioral-affective and predictive processing formulation, we theorize that sub-optimal illness and health concepts, altered interoceptive modeling, biased illness-based predictions and attention, and aberrant prediction error learning are mechanisms relevant to PHA requiring more research. Comprehensively investigating the pathophysiology of PHA offers the potential to identify adjunctive diagnostic biomarkers and catalyze new biologically-informed treatments.

Functional Neurological Disorder: Diagnostic Pitfalls and Differential Diagnostic Considerations

Functional neurologic disorder (FND) is a "rule-in" diagnosis, characterized by positive examination signs or semiological features. Similar to other clinical diagnoses, providers should ideally see robustly present features, including if possible the identification of multiple features consistent with FND for the diagnosis to be made with a high degree of certainty. Diagnostic pitfalls need to be guarded against and vary depending on FND symptom subtype and the specific patient presentation. This perspective article aims to review pitfalls based on an FND symptom subtype, as well as discuss differential diagnostic considerations with respect to both neurologic and psychiatric entities.