The Neuroanatomy of Somatoform Disorders: A Magnetic Resonance Imaging Study

Microstructural Differences of the Cerebellum-Thalamus-Basal Ganglia-Limbic Cortex in Patients with Somatic Symptom Disorders: a Diffusion Kurtosis Imaging Study

Somatic symp tom disorders (SSDs) are a group of psychiatric disorders characterized by persistent disproportionate concern and obsessive behaviors regarding physical conditions. Currently, SSDs lack effective treatments and their pathophysiology is unclear. In this paper, we aimed to examine microstructural abnormalities in the brains of patients with SSD using diffusion kurtosis imaging (DKI) and to investigate the correlation between these abnormalities and clinical indicators. Diffusion kurtosis images were acquired from 30 patients with SSD and 30 healthy controls (HCs). Whole-brain maps of multiple diffusion measures, including fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD), mean diffusivity (MD), mean kurtosis (MK), radial kurtosis (RK), and axial kurtosis (AK), were calculated. To analyze differences between the two groups, nonparametric permutation testing with 10,000 randomized permutations and threshold-free cluster enhancement was used with family-wise error-corrected p values < 0.05 as the threshold for statistical significance. Then, the correlations between significant changes in these diffusion measures and clinical factors were examined. Compared to HCs, patients with SSD had significantly higher FA, MK, and RK and significantly lower MD and RD in the cerebellum, thalamus, basal ganglia, and limbic cortex. The FA in the left caudate and the pontine crossing tract were negatively correlated with disease duration; the MD and the RD in the genu of the corpus callosum were positively correlated with disease duration. Our findings highlight the role of the cerebellum-thalamus-basal ganglia-limbic cortex pathway, especially the cerebellum, in SSDs and enhance our understanding of the pathogenesis of SSDs.

The Amplification of Symptoms in the Medically Ill

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

Case Report: Somatoform Autonomic Dysfunction-Urogenital System

Background: Somatoform autonomic dysfunction is characterized by symptoms that are autonomically perceived to appear from a particular organic disorders in which those symptoms can not be explained by any medical reasoning. In individuals with urogenital somatoform autonomic dysfunction, frequent urination accompanied with lower abdominal pain are common and treatment strategy is usually based on psychodynamic intervention.  Case Report: Ms. A 28 year old woman visited Psychiatry outpatient clinic in Universitas Sumatera Utara Hospital due to increased urination frequency, accompanied with lower abdominal pain. Interestingly, she also brought us her physical and laboratory (including urinary test) which all showed normal result. Ms. A is a cosmetologist, selling cosmetic products in department store and currently single. When we explored further about her childhood, she admitted that she has always been very neat and that her mother is very strict about tidiness and cleanliness.  Conclusion: Ms. A was diagnosed with somatoform autonomic dysfunction. The fact that she is still single while her younger sister is already in a relationship could be a stressor for her. From psychodynamic point of view, Ms. A uses regression as a coping method. Pharmacotherapy as well as psychotherapy were used. 

A Longitudinal Study on Attenuated Structural Covariance in Patients With Somatic Symptom Disorder

OBJECTIVE

This study was performed to investigate altered regional gray matter volume (rGMV) and structural covariance related to somatic symptom disorder (SSD) and longitudinal changes after treatment. Additionally, this study examined the relationships of structural alteration with its phenotypic subtypes.

METHODS

Forty-three unmedicated patients with SSD and thirty normal controls completed psychological questionnaires and neurocognitive tests, as well as brain magnetic resonance imaging. Voxel-based morphometry and structural covariances were compared between groups and between subgroups within the SSD group. After 6 months of treatment, SSD patients were followed up for assessments.

RESULTS

Patients with SSD exhibited attenuated structural covariances in the pallidal-cerebellar circuit (FDR < 0.05-0.1), as well as regions in the default mode and sensorimotor network (FDR < 0.2), compared to normal controls. The cerebellar rGMVs were negatively correlated with the severity of somatic symptoms. In subgroup analyses, patients with somatic pain showed denser structural covariances between the bilateral superior temporal pole and left angular gyrus, the left middle temporal pole and left angular gyrus, and the left amygdala and right inferior orbitofrontal gyrus, while patients with headache and dizziness had greater structural covariance between the right inferior temporal gyrus and right cerebellum (FDR < 0.1-0.2). After 6 months of treatment, patients showed improved symptoms, however there was no significant structural alteration.

CONCLUSION

The findings suggest that attenuated structural covariance may link to dysfunctional brain network and vulnerability to SSD; they also suggested that specific brain regions and networks may contribute to different subtypes of SSD.

Effects of spinal cord stimulation on voxel-based brain morphometry in patients with failed back surgery syndrome

OBJECTIVE

Despite the clinical effectiveness of Spinal Cord Stimulation (SCS), potential structural brain modifications have not been explored. Our aim was to identify structural volumetric changes during subsensory SCS, in patients with Failed Back Surgery Syndrome (FBSS).

METHODS

In this cohort study, twenty-two FBSS patients underwent a magnetic resonance imaging protocol before SCS and 3 months after SCS. Clinical parameters were correlated with volumetric changes, calculated with voxel-based morphometry.

RESULTS

After 3 months, a significant volume decrease was found in the inferior frontal gyrus, precuneus, cerebellar posterior lobe and middle temporal gyrus. Significant increases were found in the inferior temporal gyrus, precentral gyrus and the middle frontal gyrus after SCS. Additionally, significant increases in volume of superior frontal and parietal white matter and a significant decrease in volume of white matter underlying the premotor/middle frontal gyrus were revealed after SCS. A significant correlation was highlighted between white matter volume underlying premotor/middle frontal gyrus and leg pain relief.

CONCLUSIONS

This study revealed for the first time that SCS is able to induce volumetric changes in gray and white matter, suggesting the reversibility of brain alterations after chronic pain treatment.

SIGNIFICANCE

Volumetric brain alterations are observable after 3 months of subsensory SCS in FBSS patients.

Reduced gray matter volume in patients with retinal detachment: evidence from a voxel-based morphometry study

Background

We know little about the pathogenesis and diagnosis of retinal detachment.

Purpose

To assess spontaneous changes in the cerebral cortex of patients with retinal detachment using voxel-based morphometry and to explore the relationship between retinal detachment and clinical behavioral performance.

Material and Methods

Patients (14 men, 6 women; average age = 49.15 ± 10.32 years) with rhegmatogenous retinal detachment (duration of 24.05 ± 19.61 days) and 20 matched healthy controls were recruited. All participants underwent repeated functional magnetic resonance imaging scans. The original three-dimensional T1 brain images were analyzed using voxel-based morphometry and whole brain white matter volume and whole brain gray matter volume were compared with those of the control group. A receiver operating characteristic (ROC) curve was used to classify the mean gray matter volume values of the patients with retinal detachment compared with the controls.

Results

Compared with the controls, whole brain gray matter volume was significantly reduced in patients with retinal detachment, as evidenced by changes in the right inferior frontal gyrus, right superior temporal gyrus, right anterior cingulate gyrus, and right cuneus. In addition, the posterior lobe of the cerebellum, left hippocampus, left cingulate gyrus, and left middle temporal gyrus were also obviously atrophied. Furthermore, whole brain white matter volume of the patients with retinal detachment showed a slight reduction. The ROC curve analysis of each brain region showed that the accuracy of the area under the curve was high.

Conclusion

We proved that patients with retinal detachment had unusual changes in the gray matter volume and white matter volume in vision-related brain regions, which could reveal potential pathological mechanisms of retinal detachment.

Impaired Mind-Body Connections in Psychosomatic Patients: A Contemporary Neuropsychodynamic Model

In alexithymia-type psychosomatic patients who do not have the capacity to mentalize, arousal is experienced non-symbolically within the body. These people also often have significant histories of attachment trauma and other adverse childhood experiences. This article extends a previous neuropsychodynamic formulation that takes into account recent work on how attachment trauma is internalized in developing brain circuits. Specifically, it considers the possibility that early attachment trauma impairs thalamo-amygdala-striatal-thalamic circuits, resulting in disconnect of subcortical arousal to the prefrontal cortex where the arousal can be mentalized. These impaired subcortical circuits perpetuate stress deep within these patients' implicit procedural circuitry, making them very resistant to psychotherapy. Knowledge of this interaction deepens our understanding of these patients, who suffer greatly, and suggests guidelines for treatment approaches with which they are more likely to engage.