How many functional somatic syndromes?

A multivariate Swedish national twin-sibling study in women of major depression, anxiety disorder, fibromyalgia, and irritable bowel syndrome

BACKGROUND

Functional Somatic Disorders (FSD) and Internalizing Psychiatric Disorders (IPD) are frequently comorbid and likely share familial/genetic risk factors.

METHODS

We performed a Common Factor Multivariate Analysis of 2 FSDs, Fibromyalgia (FM) and Irritable Bowel Syndrome (IBS), and two IPDs, Major Depression (MD) and Anxiety Disorders (AD), in five kinds of Swedish female-female relative pairs: monozygotic (n = 8,052) dizygotic (n = 7216), full siblings (n = 712,762), half-siblings reared together (n = 23,623), and half-siblings reared apart (n = 53,873). Model fitting was by full information maximum likelihood using OpenMx.

RESULTS

The best-fit model included genetic, shared environmental, and unique environmental factors. The common factor, ~50% heritable with a small shared environmental effect, loaded more strongly on the two IPDs (~0.80) than the 2 FSDs (0.40). Disorder-specific genetic effects were larger for the 2 FSDs (~0.30) than the 2 IPDs (~0.03). Estimated genetic correlations were high for MD and AD (+0.91), moderate between IBS and IPDs (+0.62), and intermediate between FM and MD (+0.54), FM and AD (+0.28), and FM and IBS (+0.38). Shared environmental influences on all disorders were present but small.

CONCLUSIONS

In women, FSDs and IPDs shared a moderate proportion of their genetic risk factors, greater for IBS than for FM. However, the genetic sharing between IBS and FM was less than between MD and AD, suggesting that FSDs do not form a highly genetically coherent group of disorders. The shared environment made a modest contribution to the familial aggregation of FSDs and IPDs.

Multivariate, Multi-omic Analysis in 799,429 Individuals Identifies 134 Loci Associated with Somatoform Traits

Somatoform traits, which manifest as persistent physical symptoms without a clear medical cause, are prevalent and pose challenges to clinical practice. Understanding the genetic basis of these disorders could improve diagnostic and therapeutic approaches. With publicly available summary statistics, we conducted a multivariate genome-wide association study (GWAS) and multi-omic analysis of four somatoform traits-fatigue, irritable bowel syndrome, pain intensity, and health satisfaction-in 799,429 individuals genetically similar to Europeans. Using genomic structural equation modeling, GWAS identified 134 loci significantly associated with a somatoform common factor, including 44 loci not significant in the input GWAS and 8 novel loci for somatoform traits. Gene-property analyses highlighted an enrichment of genes involved in synaptic transmission and enriched gene expression in 12 brain tissues. Six genes, including members of the CD300 family, had putatively causal effects mediated by protein abundance. There was substantial polygenic overlap (76-83%) between the somatoform and externalizing, internalizing, and general psychopathology factors. Somatoform polygenic scores were associated most strongly with obesity, Type 2 diabetes, tobacco use disorder, and mood/anxiety disorders in independent biobanks. Drug repurposing analyses suggested potential therapeutic targets, including MEK inhibitors. Mendelian randomization indicated potentially protective effects of gut microbiota, including Ruminococcus bromii. These biological insights provide promising avenues for treatment development.

Recognition, explanation, action, learning: Teaching and delivery of a consultation model for persistent physical symptoms

OBJECTIVE

To describe the teaching and delivery of an extended consultation model designed for clinicians to use with patients with persistent physical symptoms and functional disorders. The model is underpinned by current scientific knowledge about persistent physical symptoms and the communication problems that arise in dealing with them.

METHODS

Process evaluation of training and delivery of the Recognition, Explanation, Action, Learning (REAL) model within the Multiple Symptoms Study 3: a randomised controlled trial of an extended-role GP "Symptoms Clinic". Evaluation used clinician and patient interviews and consultation transcripts.

RESULTS

7 GPs were trained in the intervention and 6 of them went on to deliver the REAL model in Symptoms Clinics either face-to-face or online. The Symptoms Clinic provided a set of 4 extended consultations to approximately 170 patients. Evaluation of training indicated that there was a considerable load in terms of new knowledge and skills. Evaluation of delivery found clinicians could adapt the model to individual patients while maintaining a high level of fidelity to its core components.

CONCLUSION

REAL is a teachable consultation model addressing specific clinical communication issues for people with persistent physical symptoms.

PRACTICE IMPLICATIONS

REAL enables clinicians to explain persistent physical symptoms in a beneficial way.

Personality, psychosocial and oral behavioural risk factors for temporomandibular disorder symptoms in Asian young adults

BACKGROUND

The relation between personality, psychosocial factors, somatisation, andoral behaviours as risk factors to temporomandibular disorder symptoms have notbeen well established.

OBJECTIVES

This study examined the association of temporomandibular disorder (TMD) symptoms with personality traits, psychological distress, somatisation and oral behaviours. The psychosocial and oral behavioural risk factors for TMD symptoms were also established in Asian young adults.

METHODS

Participants were recruited from a large private University. Based on the quintessential five TMD symptoms (5Ts) of the DC/TMD, the participants were stratified into those with no (NT), painful (PT), dysfunctional (DT) and mixed (MT) TMD symptoms. Personality traits, psychological distress, somatisation and oral behaviours were evaluated with the Big Five Inventory-10 (BFI-10), Depression, Anxiety, Stress Scales-21 (DASS-21), Patient Health Questionnaire-15 (PHQ-15) and Oral Behaviours Checklist (OBC) accordingly. Data were examined using Kruskal-Wallis/Mann-Whitney U and Chi-squared tests, as well as multivariate logistic regression analysis (α = .05).

RESULTS

Of the 420 young adults (mean age 22.7 ± 1.1 years) evaluated, 41.4% had no TMD symptoms, while 17.4%, 20.0% and 21.2% reported PT, DT and MT, respectively. Though personality traits did not vary notably, participants with MT and PT had significantly higher levels of negative affectivity, anxiety and stress than the NT group. Moreover, those with MT and PT presented significantly greater somatisation and more oral behaviours than the DT and NT groups. Multivariate regression analyses indicated that anxiety, somatisation, sleep-related and waking-state nonfunctional oral activities were associated with painful and/or dysfunctional TMD symptoms.

CONCLUSIONS

Except for sleep-related oral activity, psychosocial and oral behavioural risk factors differed for painful, dysfunctional and mixed TMD symptoms in Asian young adults.

Longevity of Post-Explantation Systemic Symptom Improvement and Potential Etiologies: Findings From the ASERF Systemic Symptoms in Women-Biospecimen Analysis Study: Part 4

BACKGROUND

Breast Implant Illness (BII) describes a variety of symptoms reported by patients with breast implants. Biospecimens data revealed minimal statistical differences between BII and non-BII cohorts. Baseline analysis of PROMIS data demonstrated significant differences between the BII cohort and the 2 control cohorts.

OBJECTIVES

This study was designed to determine if patients in the BII cohort obtained any symptom improvement after explantation, whether symptom improvement was related to the type of capsulectomy, and which symptoms improved.

METHODS

A prospective blinded study enrolled 150 consecutive patients divided equally into 3 cohorts. Baseline demographic data and a systemic symptoms survey, including PROMIS validated questionnaires, were obtained at baseline, 3 to 6 weeks, 6 months, and 1 year.

RESULTS

A total of 150 patients were enrolled between 2019 and 2021. Follow-up at 1 year included 94% of the BII cohort and 77% of non-BII and mastopexy cohorts. At 1 year, 88% of patients showed at least partial symptom improvement, with a reduction of 2 to 20 symptoms. The PROMIS score in the BII cohort decreased at 1 year for anxiety, sleep disturbances, and fatigue. Systemic symptom improvement was noted out to 1 year in the BII cohort regardless of the type of capsulectomy performed.

CONCLUSIONS

Parts 1-3 in this series concluded that there were no consistent differences in biospecimen results between the cohorts. Unlike the data observed in the biospecimen analysis, BII patients had heightened symptoms and poorer PROMIS scores at baseline compared to the control cohorts. The reduction of negative expectations and a potential nocebo effect could contribute to this improvement.

LEVEL OF EVIDENCE: 4

Aetiological Understanding of Fibromyalgia, Irritable Bowel Syndrome, Chronic Fatigue Syndrome and Classificatory Analogues: A Systematic Umbrella Review

Background

This umbrella review systematically assesses the variety and relative dominance of current aetiological views within the scientific literature for the three most investigated symptom-defined functional somatic syndromes (FSS) and their classificatory analogues within psychiatry and psychology.

Method

An umbrella review of narrative and systematic reviews with and without meta-analyses based on a search of electronic databases (PubMed, Web of Science, Embase, PsychINFO) was conducted. Eligible reviews were published in English, focused on research of any kind of aetiological factors in adults diagnosed with fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), and somatic symptom disorder (SSD)/somatoform disorder (SFD).

Results

We included 452 reviews (132 systematic reviews including meta-analyses, 133 systematic reviews, 197 narrative reviews), of which 132 (29%) focused on two or more of the investigated health conditions simultaneously. Across diagnoses, biological factors were addressed in 90% (k = 405), psychological in 33% (k = 150), social in 12% (k = 54), and healthcare factors in 5% (k = 23) of the reviews. The methodological quality of the included systematic reviews (k = 255) was low (low/critically low: 41% [k = 104]; moderate: 49% [k = 126]; high quality: 10% [k = 25]). The high-quality systematic reviews suggest that deficient conditioned pain modulation, genetic factors, changes in the immune, endocrinological, gastrointestinal, cardiovascular, and nervous system, and psychosocial factors such as sexual abuse and pain catastrophizing increase the risk for FSS.

Conclusion

Only very few systematic reviews have used comprehensive, biopsychosocial disease models to guide the selection of aetiological factors in FSS research. Future research should strive for higher scientific standards and broaden its perspective on these health conditions.

A distinctive profile of family genetic risk scores in a Swedish national sample of cases of fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome compared to rheumatoid arthritis and major depression

BACKGROUND

Functional somatic disorders (FSD) feature medical symptoms of unclear etiology. Attempts to clarify their origin have been hampered by a lack of rigorous research designs. We sought to clarify the etiology of the FSD by examining the genetic risk patterns for FSD and other related disorders.

METHODS

This study was performed in 5 829 186 individuals from Swedish national registers. We quantified familial genetic risk for FSD, internalizing disorders, and somatic disorders in cases of chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS), using a novel method based on aggregate risk in first to fifth degree relatives, adjusting for cohabitation. We compared these profiles with those of a prototypic internalizing psychiatric - major depression (MD) - and a somatic/autoimmune disorder: rheumatoid arthritis (RA).

RESULTS

Patients with FM carry substantial genetic risks not only for FM, but also for pain syndromes and internalizing, autoimmune and sleep disorders. The genetic risk profiles for IBS and CFS are also widely distributed although with lower average risks. By contrast, genetic risk profiles of MD and RA are much more restricted to related conditions.

CONCLUSION

Patients with FM have a relatively unique family genetic risk score profile with elevated genetic risk across a range of disorders that differs markedly from the profiles of a classic autoimmune disorder (RA) and internalizing disorder (MD). A similar less marked pattern of genetic risks was seen for IBS and CFS. FSD arise from a distinctive pattern of genetic liability for a diversity of psychiatric, autoimmune, pain, sleep, and functional somatic disorders.

Impact of comorbidity on symptomatology in various types of environmental intolerance in a general Swedish and Finnish adult population

Comorbidity with various health conditions is common in environmental intolerances (EIs), which restricts understanding for what symptoms that are associated with the intolerance per se. The present objectives were to study (i) prevalence of a broad range of specific symptoms in chemical, building-related, electromagnetic field- (EMF) related, and sound EI, irrespective of comorbidity, (ii) prevalence of symptoms in body systems in exclusive EIs, and (iii) increased risk of symptoms in body systems in exclusive EIs that cannot be referred to functional somatic syndromes, inflammatory diseases or mental disorders. Cross-sectional data (n = 4941) were used from two combined population-based surveys, the Västerbotten (Sweden) and Österbotten (Finland) Environmental Health Studies. Categorization of EI cases and controls were based on self-reports. Symptoms were assessed with the Environmental Hypersensitivity Symptom Inventory, and these were converted to 27 symptoms of the International Classification of Primary Care, 2nd edition, in eight chapters of body systems. The results showed, with few exceptions, that all assessed specific symptoms were significantly more prevalent in all four EIs than in referents. Although a large overlap between EIs, characteristic body system symptoms were eye and respiratory symptoms in chemical and building-related intolerance, skin symptoms in EMF-related intolerance, and general and unspecified, digestive, eye, cardiovascular, neurological, and psychological symptoms in sound intolerance. After controlling for various comorbidities, all studied body system symptoms were positively associated with chemical intolerance, fewer with sound intolerance, only one with building-related intolerance, and none with EMF-related EI. In conclusion, a broad range of symptoms are reported in all four EIs implying common mechanisms, but symptoms of certain body systems are more likely to be reported in a certain EI that cannot be explained by comorbidity.

Internet-delivered treatment for patients suffering from severe functional somatic disorders: Protocol for a randomized controlled trial

Background

Functional somatic disorders (FSDs) with symptoms from multiple organs, i.e., multi-system type, are common in the general population and may lead to disability and reduced quality of life. Evidence for efficient treatment programs has been established, however, there is a need for making treatments accessible to a larger group of patients. Internet-delivered therapy has become prevalent and has proven as effective as face-to-face therapy, while providing a flexible and easily accessible treatment alternative. The aim of the current study is to compare the efficacy of the therapist-assisted internet-delivered treatment program One step at a time (OneStep) with the internet-delivered self-help program Get started (GetStarted).

Methods

A total of 166 participants aged 18-60 years diagnosed with multi-system FSD will be assessed and randomized to either 1) OneStep: a 14-week program consisting of 11 treatment modules based on principles from cognitive behavioural therapy or 2) GetStarted consisting of 1 module on psychoeducation. The primary outcome is physical health, assessed by a Short Form Health Survey (SF-36) aggregate score of the subscales vitality, physical functioning, and bodily pain 3 months after end-of-treatment and self-reported improvement assessed by the Clinical Global Improvement Scale. Secondary outcomes include symptom load, depression, anxiety, and illness worry. Process measures include emotional distress, illness perception, illness behaviour, and symptom interference.

Conclusions

This study is the first study to test an internet-delivered treatment program for FSD, multi-system type and has the potential to show the importance of making evidence-based internet-delivered treatment for FSD more accessible.

Interoceptive accuracy and bias in somatic symptom disorder, illness anxiety disorder, and functional syndromes: A systematic review and meta-analysis

Somatic symptom disorder, illness anxiety disorder, and functional syndromes are characterized by burdensome preoccupation with somatic symptoms. Etiological models propose either increased interoceptive accuracy through hypervigilance to the body, or decreased and biased interoception through top-down predictions about sensory events. This systematic review and meta-analysis summarizes findings of 68 studies examining interoceptive accuracy and 8 studies examining response biases in clinical or non-clinical groups. Analyses yielded a medium population effect size for decreased interoceptive accuracy in functional syndromes, but no observable effect in somatic symptom disorder and illness anxiety disorder. The overall effect size was highly heterogeneous. Regarding response bias, there was a small significant effect in somatic symptom disorder and illness anxiety disorder. Our findings strengthen the notion of top-down factors that result in biased rather than accurate perception of body signals in somatic symptom disorder and illness anxiety disorder.

Mechanisms of change in multicomponent group-based treatment for patients suffering from medically unexplained physical symptoms

Understanding psychological mechanisms of change is essential to advance treatments for patients suffering from medically unexplained physical symptoms (MUPS). This study aimed to test the role of selected change mechanisms (incl. interoceptive awareness, emotional regulation skills, symptom acceptance, relational needs satisfaction, clarification of meaning, working alliance, and group cohesion) in the modification of patients' somatic symptom intensity and well-being.

N = 290 patients suffering from MUPS participated in a multi-component group-based treatment at seven clinical sites. Data were collected weekly. Multi-level modeling was used to test cross-lagged relationships between the hypothesized mechanisms and outcomes in terms of Granger causality (with lags of 1, 2, and 3 weeks).

None of the mechanisms predicted a time-lagged change in outcomes in the expected direction. In fact, there was a consistent pattern of negative time-lagged relationships (i.e., an increase in a mechanism predicted worsening of the outcome). Findings consistent with the hypothesized role of the mechanisms were found only in concurrent relationships between mechanisms and outcomes.

This study did not support time-lagged relationships under the condition of weekly measurement and many methodological factors remain to be considered (e.g., a finer time resolution).

Early Psychological Interventions for Somatic Symptom Disorder and Functional Somatic Syndromes: A Systematic Review and Meta-Analysis

OBJECTIVE

Psychological treatments for somatic symptom disorder and functional somatic syndromes (SSD/FSS) achieve moderate effects only, potentially because of the high chronicity in these patients. Therefore, we aimed to evaluate whether early treatment, that is, treatment in populations at risk or with recent onset, improves outcome.

METHODS

We conducted a systematic review and meta-analysis of (cluster-)randomized controlled trials evaluating early psychological interventions in the prevention and treatment of SSD/FSS in adults compared with inactive control conditions, standard care, or placebo. Individuals at risk for SSD/FSS, suffering from subthreshold symptoms or new onsets of SSD/FSS, or presenting with SSD/FSS for the first time were included.

RESULTS

We identified 30 eligible studies, mostly examining pain-related conditions. Interventions were diverse, ranging from bibliotherapy to cognitive-behavioral therapy. We found positive effects on depression post-treatment (Hedges' g = 0.12 [95% confidence interval = 0.03-0.2], k = 5) as well as on somatic symptom severity (g = 0.25 [0.096-0.41], k = 17) and health care utilization (g = 0.31 [0.18-0.44], k = 3) at follow-up. However, because of a high risk of bias, sensitivity to corrections for meta-bias, and missing outcome data, findings should be interpreted cautiously.

CONCLUSIONS

Our review shows that targeting SSD/FSS at an early stage represents a conceptual and practical challenge. Readily accessible interventions addressing transsymptomatic processes of SSD/FSS development and consolidation are highly needed. Future studies are needed to evaluate individuals with diverse symptoms, examine symptom history thoroughly, use placebo controls, and report outcomes completely to determine the efficacy of early psychological interventions for SSD/FSS.PROSPERO Registration:CRD42020140122.

Psychological models of development of idiopathic environmental intolerances: Evidence from longitudinal population-based data

The origin of idiopathic environmental intolerances (IEIs) is an open question. According to the psychological approaches, various top-down factors play a dominant role in the development of IEIs. The general psychopathology model assumes a propensity towards mental ill-health (negative affectivity) increases the probability of developing IEIs. The attribution model emphasizes the importance of mistaken attribution of experienced somatic symptoms; thus, more symptoms should lead to more IEIs. Finally, the nocebo model highlights the role of expectations in the development of IEIs. In this case, worries about the harmful effects of environmental factors are assumed to evoke IEIs. We estimated cross-lagged panel models with latent variables based on longitudinal data obtained at two time points (six years apart) from a large near-representative community sample to test the hypothesized associations. Indicators of chemical intolerance, electromagnetic hypersensitivity, and sound sensitivity fit well under a common latent factor of IEIs. This factor, in turn, showed considerable temporal stability. However, whereas a positive association was found between IEIs and increased somatic symptoms and modern health worries six years later, the changes therein could not be predicted as hypothesized by the three psychological models. We discuss the implications of these results, as well as methodological aspects in the measurement and prediction of change in IEIs.

Epidemiology and organisation of care in medically unexplained symptoms: A systematic review with a focus on cultural diversity and migrants

BACKGROUND

Since the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care.

AIM

To improve healthcare provider-patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients.

METHODS

Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUPS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'.

RESULTS

Different case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned.

CONCLUSION

The systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes.

Symptom attribution to a medically unexplained syndrome is associated with greater perceived severity and bothersomeness of symptoms in US military veterans

OBJECTIVE

Medically unexplained symptoms (MUS) are prevalent among veteran and non-veteran populations. Current biopsychosocial theory implicates a multitude of factors in MUS development and perpetuation. The current study tests whether physical symptom attribution to MUS is associated with perceived symptom severity and bothersomeness and thereby might function to perpetuate MUS, as suggested by existing theory.

DESIGN AND MAIN OUTCOME MEASURES

Military combat veterans (n = 243) answered postal-mail questions about their physical symptoms, severity of experienced symptoms, and attributions of these symptoms to MUS (e.g. Gulf War Illness) versus non-MUS conditions.

RESULTS

Independent t-tests showed support for the first hypothesis-that those who experience the symptom and attribute it to MUS will perceive it to be more severe and bothersome than those who experience the symptom but do not attribute it to MUS. Paired-sample t-tests showed support for the second hypothesis-that experienced symptoms attributed to MUS by an individual will be perceived as more severe and bothersome than experienced symptoms the individual does not attribute to MUS.

CONCLUSIONS

Results highlight a potential role of symptom attribution in MUS perpetuation, through greater perceived severity and bothersomeness of MUS-attributed symptoms. Possible intervention targets may include behavior ramifications, such as coping strategies; more research is needed.

What is it like to live with medically unexplained physical symptoms? A qualitative meta-summary

Medically unexplained physical symptoms (MUPS) are a frequent phenomenon. Understanding adults and adolescents' lived experience with MUPS is essential for providing adequate care, yet a rigorous synthesis of existing studies is missing. Objective: This study aimed to summarize findings from primary qualitative studies focused on adults' and adolescents' experience of living with MUPS. Design: Qualitative studies were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. A total of 23 resources met the inclusion criteria and were subjected to a qualitative meta-summary. Results: Eight themes were found across the set of primary studies, namely, the need to feel understood, struggling with isolation, 'sense of self' in strain, facing uncertainty, searching for explanations, ambivalence about diagnosis, disappointed by healthcare, and active coping. Conclusion: The eight themes represent the core struggles adults' and adolescents' with MUPS face in their lives, psychologically and socially. Although these themes appear to be universal, the analysis also revealed considerable variability of experience in terms of expectations from healthcare professionals, attitude towards formal diagnoses, ability to cope with the illness, or potential to transform the illness experience into personal growth. Addressing this diversity of needs represents a significant challenge for the healthcare system.

PON1 polymorphisms can predict generalized anxiety and depressed mood in patients with multiple chemical sensitivity

Background: Multiple chemical sensitivity (MCS) is a chronic condition with somatic, cognitive and affective symptoms that follow contact with chemical agents at usually non toxic concentrations. We aimed to assess the role of genetic polymorphisms involved in oxidative stress on anxiety and depression in MCS. Materials & methods: Our study investigated the CAT rs1001179, MPO rs2333227, PON1 rs662 and PON1 rs705379 polymorphisms in MCS. Results: The AG genotype of the PON1 rs662 and the TT and CT genotypes of the PON1 rs705379 were involved in anxiety and depression. Discussion: These results are in line with existing evidence of PON1 involvement in MCS and suggest a further role of this gene in the exhibition of anxiety and depression in this disease.

Multiple Chemical Sensitivity Syndrome: A Principal Component Analysis of Symptoms

Multiple Chemical Sensitivity (MCS) is a chronic and/or recurrent condition with somatic, cognitive, and affective symptoms following a contact with chemical agents whose concentrations do not correlate with toxicity in the general population. Its prevalence is not well defined; it mainly affects women between 40 and 50 years, without variations in ethnicity, education and economic status. We aimed to assess the core symptoms of this illness in a sample of Italian patients. Two physicians investigated different symptoms with a checklist compilation in 129 patients with MCS (117 women). We conducted a categorical Principal Component Analysis (CATPCA) with Varimax rotation on the checklist dataset. A typical triad was documented: hyperosmia, asthenia, and dyspnoea were the most common symptoms. Patients also frequently showed cough and headache. The CATPCA showed seven main factors: 1, neurocognitive symptoms; 2, physical (objective) symptoms; 3, gastrointestinal symptoms; 4, dermatological symptoms; 5, anxiety-depressive symptoms; 6, respiratory symptoms; 7, hyperosmia and asthenia. Patients showed higher mean prevalence of factors 7 (89.9%), 6 (71.7%), and 1 (62.13%). In conclusion, MCS patients frequently manifest hyperosmia, asthenia, and dyspnoea, which are often concomitant with other respiratory and neurocognitive symptoms. Considering the clinical association that is often made with anxiety, more studies are necessary on the psychosomatic aspects of this syndrome. Further analytical epidemiological studies are needed to support the formulation of aetiological hypotheses of MCS.

New Insights about Chronic Pelvic Pain Syndrome (CPPS)

BACKGROUND

Chronic pelvic pain syndrome (CPPS) is one of the common diseases in urology and gynecology. CPPS is a multifactorial disorder where pain may originate in any of the urogynecological, gastrointestinal, pelvic musculoskeletal, or nervous systems. The symptoms of CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological, and endocrine systems. The aim of this article was to present new insight about CPPS in order to raise awareness of nursing and medical staff in the identification and diagnosis of the syndrome and to promote an appropriate treatment for each woman who suffers from CPPS.

METHODS

A literature review about the factors associated with CPPS and therapeutic interventions for CPPS was conducted.

RESULTS

CPPS represents a chronic pain syndrome that combines anatomic malfunction of the pelvic floor muscles with malfunction of pain perception linked with psychological and cognitive factors.

CONCLUSIONS

The therapeutic interventions in CPPS cases should, consequently, follow a multidisciplinary approach.

Functional somatic disorders: discussion paper for a new common classification for research and clinical use

BACKGROUND

Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs.

MAIN BODY

We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrum - and also within organ system-specific chapters of a classification - they should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD).

CONCLUSION

We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.

Irritable bowel, chronic widespread pain, chronic fatigue and related syndromes are prevalent and highly overlapping in the general population: DanFunD

Prevalence of functional somatic syndromes (FSS) in the general population varies with observed overlap between syndromes. However, studies including a range of FSS are sparse. We investigated prevalence and characteristics of various FSS and the unifying diagnostic construct bodily distress syndrome (BDS), and identified mutual overlap of the FSS and their overlap with BDS. We included a stratified subsample of 1590 adults from a randomly selected Danish general population sample (n = 7493). Telephonic diagnostic interviews performed by three trained physicians were used to identify individuals with FSS and BDS. Prevalence of overall FSS was 9.3%; 3.8% for irritable bowel, 2.2% for chronic widespread pain, 6.1% for chronic fatigue, 1.5% for whiplash associated disorders, and 0.9% for multiple chemical sensitivity. Prevalence of BDS was 10.7% where 2.0% had the multi-organ type. FSS were highly overlapping with low likelihood of having a “pure” type. Diagnostic agreement of FSS and BDS was 92.0%. Multi-syndromatic FSS and multi-organ BDS were associated with female sex, poor health, physical limitations, and comorbidity. FSS are highly prevalent and overlapping, and multi-syndromatic cases are most affected. BDS captured the majority of FSS and may improve clinical management, making the distinction between multi- and mono-syndromatic patients easier.

"Symptoms associated with environmental factors" (SAEF) - Towards a paradigm shift regarding "idiopathic environmental intolerance" and related phenomena

Health conditions characterized by symptoms associated with chemical, physical and biological environmental factors unrelated to objectifiable pathophysiological mechanisms are often labelled by the general term "idiopathic environmental intolerances". More specific, exposure-related terms are also used, e.g. "multiple chemical sensitivities", "electromagnetic hypersensitivity" and "candidiasis hypersensitivity". The prevalence of the conditions varies from a few up to more than 50%, depending on definitions and populations. Based on evolving knowledge within this field, we provide arguments for a paradigm shift from terms focusing on exposure and intolerance/(hyper-)sensitivity towards a term more in line with the perceptual elements that seem to underlie these phenomena. Symptoms caused by established pathophysiologic mechanisms should not be included, e.g. allergic or toxicological conditions, lactose intolerance or infections. We discuss different alternatives for a new term/concept and end up proposing an open and descriptive term, "symptoms associated with environmental factors" (SAEF), including a definition. "Symptoms associated with environmental factors" both is in line with the current knowledge and acknowledge the experiences of the afflicted persons. Thus, the proposed concept is likely to facilitate therapy and communication between health professionals and afflicted persons, and to provide a base for better understanding of such phenomena in healthcare, society and science.

The unifying diagnostic construct of bodily distress syndrome (BDS) was confirmed in the general population

OBJECTIVES

Bodily distress syndrome (BDS) has been shown to encompass a range of functional somatic syndromes (FSS) such as irritable bowel syndrome (IBS), fibromyalgia (FM), and chronic fatigue syndrome (CFS) in clinical samples. This study aimed to explore symptom clusters and test classification of individuals with illness similar to the BDS criteria in a general population sample.

METHODS

A stratified subsample of 1590 individuals from the DanFunD part two cohort was included. Symptoms were assessed with the Research Interview for Functional somatic Disorders, performed by trained physicians. In 44 symptoms pooled from criteria of IBS, FM, CFS, and BDS, symptom clusters were explored with explorative factor analysis. Confirmation of symptom clusters of BDS in the previously described 25- and 30-item BDS checklists was performed with confirmatory factor analysis. Classification of individuals into illness groups was investigated with latent class analysis.

RESULTS

Four symptom clusters (cardiopulmonary, gastrointestinal, musculoskeletal, general symptoms/fatigue) corresponding to the BDS subtypes and their corresponding FSS were identified and confirmed. A three-class model including 25 BDS items had the best fit for dividing participants into classes of illness: One class with low probability, one class with medium probability, and one class with high probability of having ≥4 symptoms in all symptom clusters.

CONCLUSION

The BDS concept was confirmed in the general population and constitutes a promising approach for improved FSS classification. It is highly clinical relevant being the only diagnostic construct defining the complex multi-organ type.

"Understand your illness and your needs": Assessment-informed patient education for people with multiple functional somatic syndromes

OBJECTIVES

Patients suffering from multiple functional somatic syndromes (FSS) such as fibromyalgia, chronic fatigue syndrome, or irritable bowel syndrome, often lack both a clear diagnosis and tangible illness explanations, which is a barrier for treatment engagement. We tested a short-term intervention taking the unifying concept of Bodily Distress Syndrome (BDS) as a point of departure. The intervention consisted of a clinical assessment, group-based patient education, and one follow-up consultation.

METHODS

174 patients were included and received questionnaires at baseline, after clinical assessment, after patient education, and median 19 weeks after baseline. Data were analyzed using random effects models and simple t-tests. Qualitative data were thematically analyzed.

RESULTS

We found small reductions in symptom levels, considerable reductions in illness worry, and improvement of illness perceptions and illness-related behaviors. Overall, patients evaluated the intervention positively and expressed high expectations for further treatment. Qualitative results mainly supported these findings.

CONCLUSION

Targeting illness perceptions through patient education is crucial to obtain patient engagement in self-help management or further treatment. This may lead to improved outcomes.

PRACTICAL IMPLICATIONS

Physicians in primary and secondary care should strive to give patients with multiple FSS a clear understanding that their various FSS diagnoses are related and provide tangible illness explanations.

Prevalence of functional somatic syndromes and bodily distress syndrome in the Danish population: the DanFunD study

Aims: Little is known about the prevalence and characteristics of functional somatic syndromes (FSS) such as irritable bowel syndrome (IBS), fibromyalgia (FM), chronic fatigue syndrome (CFS), whiplash associated disorders (WAD), multiple chemical sensitivity (MCS), and bodily distress syndrome (BDS) in the general population when they are investigated simultaneously. Method: This cross-sectional study is based on the Danish Study of Functional Disorders (DanFunD) cohort consisting of 9656 adults from the general population. FSS and BDS were identified by questionnaires and characterized by age, sex, vocational training, physical health and comorbidity with physical and psychiatric disease. Results: In total, 16.3% (95% CI: 15.6–17.1) of the participants fulfilled the criteria for at least one FSS, ranging from 1.7% for WAD to 8.6% for CFS, and 16.1% (95% CI: 15.4–16.9) fulfilled the criteria for BDS. Cases had a high risk of poor self-perceived health, limitations in daily activities, and a high psychiatric comorbidity, all increasing with the number of syndromes in each individual. However, the associations differed across the various FSS. Mutual overlaps of IBS, FM and CFS were greater than could be expected by chance. Conclusions: FSS and BDS are prevalent in the adult Danish population, and cases have high risk of poor self-perceived health, limitation in daily activities, and psychiatric comorbidity. These associations were particularly strong for cases with multiple FSS and multi-organ BDS.

Common therapeutic strategies in psychological treatments for medically unexplained somatic symptoms

Objective: Medically unexplained somatic symptoms (MUSS) represent a frequent complaint in health care services. While psychological treatments have demonstrated some effect in patients with MUSS, further progress may be achieved by a synthesis of clinical strategies used in diverse treatment models. The aim of this study was to identify clinical strategies shared across multiple psychological treatments intended for the treatment of adult patients with MUSS. Method: Descriptions of psychological treatments for patients with MUSS were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. N = 135 resources met inclusion criteria and were subjected to qualitative analysis. Results: Similarities across treatments were captured in 8 broad categories and 18 subcategories that covered aspects of the therapeutic relationship, specific skills (bodily, emotional, and relational) for patients to develop, search for the meaning of symptoms, and the orientation on life beyond symptoms. Conclusions: Despite the differences in technique, it was possible to identify common therapeutic strategies in psychological treatments for patients with MUSS. These overarching treatment strategies, many of which have already obtained empirical support, may inspire further research and the development of comprehensive treatments with enhanced efficacy. Limitations of the present study include the lack of focus on specific syndromes.

Prevalence of medically unexplained symptoms in adults who are high users of health care services: a systematic review and meta-analysis protocol

INTRODUCTION

Medically unexplained symptoms (MUS) are common in primary-care and secondary-care settings. Persistent symptoms of MUS are associated with a variety of poor outcomes including increased disability, poor quality of life and high healthcare costs. The aim of this systematic review is to review the relevant literature to determine the prevalence of MUS in patients who are high users of healthcare and/or who accrue high healthcare costs.

METHODS AND ANALYSIS

This review will include studies with cases that are either high users of general healthcare or are patients who accrue high healthcare costs, aged ≥18 years and where a recognised measure of MUS, either a standardised clinical interview or questionnaire, was employed. The following citation databases MEDLINE, PsycINFO, EMBASE, CINAHL, PROSPERO and the Cochrane library will be systematically searched from inception to 30 June 2018. The Cochrane library was included because of the significant proportion of non-observational studies currently published in the database. The prevalence of MUS and associated disorders along with the costs or use of healthcare associated with the presence of MUS will be estimated with 95% CI. If possible, study results will be pooled into a meta-analysis. However, if heterogeneity is high, data analysis will be presented descriptively.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review since only data from existing studies will be used. Results of this review will be disseminated in peer-reviewed publications and at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42018100388.

Symptom frequency and development of a generic functional disorder symptom scale suitable for use in studies of patients with irritable bowel syndrome, fibromyalgia syndrome or chronic fatigue syndrome

Objectives

To describe the extent to which irritable bowel syndrome (IBS), fibromyalgia syndrome (FMS), and chronic fatigue syndrome (CFS) exhibit symptom overlap, and to validate a patient-derived, generic symptom questionnaire.

Methods

A patient-derived 61-item symptom-frequency questionnaire was completed by participants recruited through IBS, FMS and CFS self-help websites. Principal axis factor analysis with oblimin rotation was performed separately for those reporting an IBS, FMS or CFS diagnosis.

Results

Questionnaires were completed by 1751 participants of whom 851 reported more than one of the three diagnoses. Stomach pain on at least a weekly basis was reported by 79% of IBS, 52% of FMS, and 43% of CFS single diagnosis participants. Pain increasing the day after activity was reported by 32% of IBS, 94% of FMS, and 85% of CFS single diagnosis participants. Waking still tired at least once weekly was reported by 75% of IBS, 97% of FMS, and 95% of CFS single diagnosis participants. Exploratory factor analysis produced consistent results across all three diagnostic groups, the 61 items loading on 12 correlated factors with a single higher order factor on which all items loaded. Frequency analysis led to the rejection of one item (cold sores on or near lips), and freeform reporting by participants of additional symptoms identified an additional five, namely, restless legs, hair loss/brittle hair/thinning, dizziness/balance problems, blurred vision and urination problems.

Conclusions

IBS, FMS and CFS are polysymptomatic spectrum disorders with a wide range of overlapping symptoms, many of which are unrelated to diagnostic criteria. Frequency analysis and factor analysis confirm the validity of using the same questionnaire across different diagnostic categories. The 65-item general symptom questionnaire (GSQ-65) is a valid generic symptom scale suitable for assessing the many different symptoms of people with IBS, FMS and CFS.

Evaluating Commonalities Across Medically Unexplained Symptoms

This commentary presents commonalities in medically unexplained symptoms (MUS) across multiple organ systems, including symptoms, aetiological mechanisms, comorbidity with mental health disorders, symptom burden and impact on quality of life. Further, treatment outcomes and barriers in the clinician–patient relationship, and cross-cultural experiences are highlighted. This discussion is necessary in aiding an improved understanding and management of MUS due to the interconnectedness underlying MUS presentations across the spectrum of medical specialties.

Attending away from the body predicts increased physical symptom reports at six months in primary care patients

OBJECTIVE

High symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients.

METHOD

Primary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores.

RESULTS

Contrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months.

CONCLUSIONS

These findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.

Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms

Background

Early adolescence is considered a critical period for the development of chronic and recurrent medically unexplained symptoms (MUS), and referrals and system-initiated patient trajectories often lead to an excess of examinations and hospitalizations in the cross-section between mental and somatic specialist care for this group of patients. Dimensions of the relationship and communication between clinician and patient are shown in primary care studies to be decisive for subsequent illness pathways, often creating adverse effects, but knowledge on clinical communication in specialist care is still scarce.

Methods

This study explores communicative challenges specific to clinical encounters between health professionals and adolescent patients in specialist care, as presented through interviews and focus group data with highly experienced specialists working in adolescent and child services at a Norwegian university hospital.

Results

The results are presented in a conceptual model describing the epistemological and methodological paradoxes inherent in the clinical uncertainty of MUS. Within these paradoxes, the professionals try to solve the dilemmas by being creative in their communication strategies; applying metaphors and other rhetorical devices to explain complex ideas; creating clinical prototypes as a way to explain symptoms and guide them in clinical action; relying on principles from patient-centered care involving empathy; and trying to balance expertise and humility.

Conclusion

The challenges in communication arise as a result of opposing discourses on biomedicine, family, health and adolescence that create dilemmas in everyday clinical work. By moving away from a positivist and biomedical framework towards an interpretive paradigm, where culturally derived and historically situated interpretations are used to understand the social life-world of the patient, one can create a more humane health service in accordance with ideals of patient-centered care.

A step towards a new delimitation of functional somatic syndromes: A latent class analysis of symptoms in a population-based cohort study

OBJECTIVES

The current delimitation of functional somatic syndromes (FSS) is inconsistent. We aimed to investigate somatic symptom profiles in the general adult population to contribute to a new, data-driven delimitation of FSS.

METHODS

Information on 31 self-reported somatic symptoms used in the delimitation of various FSS and bodily distress syndrome (BDS) was obtained from the DanFunD study-a population-based cohort study on 9656 adults (participation 33.6%) from Greater Copenhagen, Denmark. Latent class analysis was used to identify symptom profiles. The profiles were described by their relation with sex, age, chronic disease, self-perceived health, symptom impact, self-reported FSS, and BDS case-status.

RESULTS

Eight symptom profiles were identified. The largest profile had no symptoms (49% of the population). Three profiles were characterized by a few, specific symptoms: muscle and joint pain (17%), gastrointestinal symptoms (6%), and general symptoms (13%). Three profiles had multiple symptoms in specific combinations: musculoskeletal and general symptoms (7%); fatigue, musculoskeletal and gastrointestinal symptoms (3%); and cardiopulmonary, gastrointestinal and general symptoms (3%). Lastly, one profile (2%) had high probability of all symptoms. The last four profiles (15%) were strongly associated with BDS case-status, poor self-perceived health and high impact of symptoms. Analyses excluding persons with multi-symptomatic chronic disease showed similar results.

CONCLUSIONS

We identified eight symptom profiles characterized by specific combinations of symptoms. Four of these had multiple symptoms from several bodily systems showing large overlap with BDS, possibly indicating subtypes of FSS. The profiles contribute to a new delimitation of FSS by illustrating the importance of specific symptom combinations.

How do hospital doctors manage patients with medically unexplained symptoms: a qualitative study of physicians

Objective Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms. Design A qualitative study using in-depth interviews and thematic analysis. Setting Three hospitals in the North Thames area. Participants Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology. Main outcome measure Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients. Results There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor's level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care. Conclusions Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services.

Functional Somatic Syndrome: Assessment and Management

Functional somatic syndrome (FSS) occurs in as many as 30% of patients in general medical practice, but it is infrequently a topic of formal instruction. Many physicians feel uncomfortable with medically unexplained symptoms and are unfamiliar with how to assess or manage them. Traditional medical approaches can be ineffective and can contribute to iatrogenic or adverse physiologic effects in patients. Physicians treating patients with FSS should not only consider standard medical tests, but they should also try to gain a deeper behavioral understanding of the mind-body connections that underlie the presenting symptoms. Osteopathic physicians, with their emphasis on holistic patient care, are in a key position to treat patients with FSS. This review provides a brief recapitulation of the literature and illustrates key factors in the assessment and management of FSS.

Somatoform symptoms profiles in relation to psychological disorders - A population classification analysis in a large sample of general adults

In order to identifying somatoform symptoms profiles, classifying study population and evaluating of psychological disorders in extracted classes, we carried out a cross-sectional study on 4762 Iranian adults. Somatoform symptoms were assessed using a comprehensive 30-items questionnaire and psychological disorders were evaluated by 12-item General Health Questionnaire (GHQ-12) and Hospital Anxiety and Depression Scale (HADS) questionnaires. Factor analysis and factor mixture modeling (FMM) were used for data analysis. Four somatoform symptoms profiles were extracted, including 'psycho-fatigue', 'gastrointestinal', 'neuro- skeletal' and 'pharyngeal-respiratory'. According to FMM results, a two-class four-factor structure, based somatoform symptoms, was identified in our study population. Two identified classes were labeled as "low psycho-fatigue complaints" and "high psycho-fatigue complaints". The scores of psychological disorders profile was significantly associated with four somatoform symptoms profiles in both classes; however the stronger relationship was observed in high psycho-fatigue complaints class. The prevalence of all the somatoform symptoms among participants assigned to the "high psycho-fatigue complaints" class was significantly higher than other class. We concluded that somatoform symptoms have a dimensional-categorical structure within our study population. Our study also provided informative pathways on the association of psychological disorders with somatoform symptoms. These findings could be useful for dealing with treatment's approaches.

The relationship between salivary amylase and the physical and psychological changes elicited by continuation of autogenic training in patients with functional somatic syndrome

Background

The aim of this study was to clarify the changes in biological measures during autogenic training (AT) sessions and the relationship between these biological measures and the changes in physical and psychological measures induced by continuation of AT in patients with functional somatic syndrome (FSS). We used the salivary amylase (SAMY) level, skin temperature of the finger (TEMP), subjective symptom scores, and psychological characteristics to assess these changes.

Methods

We assessed 24 patients with FSS and 23 healthy controls before and after AT. We then conducted the same tests after the participants had practiced AT at home 1 and 2 months later.

Results

The baseline SAMY levels in the first session were significantly higher in the FSS group than in the control group. However, this difference was not significant in the second and third sessions. The pattern of changes in TEMP induced by AT was not different between the FSS and control groups. Tension-anxiety and somatic symptoms in patients with FSS were improved by AT. In the FSS group, the baseline SAMY levels in the first session showed a significant negative correlation with the changes in the subjective symptom score and tension-anxiety score at baseline.

Conclusions

The practice of AT, both during the first session and after 1 month of continuation, eased the dysregulation of the autonomic nervous system that is reflected in SAMY in patients with FSS. AT also contributed to decreases in the tension-anxiety and somatic symptoms in patients with FSS. We suggest that SAMY is related to both physical and psychological effects of AT in patients with FSS.

High healthcare utilization near the onset of medically unexplained symptoms

OBJECTIVE

Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization.

METHODS

Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n=336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA).

RESULTS

Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope=-0.26, F=4.07, p=0.04), specialist (slope=-0.43, F=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope=-0.41, F=5.71, p=0.02) and mental health (slope=-0.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden.

CONCLUSION

This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.

Saliva amylase as a measure of sympathetic change elicited by autogenic training in patients with functional somatic syndromes

The aim of this study was to discuss the effect of autogenic training (AT) on patients with functional somatic syndrome (FSS) using salivary amylase, the skin temperature of the finger, subjective severity of symptoms, and psychological characteristics as measures. We assessed 20 patients with FSS and 23 healthy controls before and after AT. Baseline levels of salivary amylase prior to an AT session were significantly higher in the FSS group than in the control group. However, this difference was not significant after AT. The skin temperature of the finger increased after AT in both the FSS and control groups. AT contributed to the improvement of somatic symptoms in patients with FSS. Our results regarding psychological characteristics suggest that mood disturbances are deeply involved in the pathology of FSS. Individuals with FSS exhibited elevated levels of sympathetic activity compared with healthy controls. Our data indicates that AT eased dysregulation of the autonomic nervous system in patients with FSS. Thus, salivary amylase may be a useful index of change induced by AT in patients with FSS.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

Programmed symptoms: disparate effects united by purpose

Central sensitivity syndromes (CSS) share features of similar multiple symptoms, virtually unknown mechanisms and lack of effective treatments. The CSS nomenclature was chosen over alternatives because it focused on a putative physiological mechanism of central sensitization common to disorders such as fibromyalgia, irritable bowel syndrome, vulvodynia and temporomandibular disorder. Increasing evidence from multiple biological systems suggests a further development. In this new model central sensitization is part of a ensemble that includes also the symptoms of widespread pain, fatigue, unrefreshing sleep and dyscognition. The main feature is an intrinsic program that produces this ensemble to guide behavior to restore normal function in conditions that threaten survival. The well known “illness response” is a classic example that is triggered in response to the specific threat of viral infection. The major leap for this model in the context of CSS is that the symptom complex is not a reactive result of pathology, but a purposeful feeling state enlisted to combat pathology. Once triggered, this state is produced by potential mechanisms that likely include contributions of the peripheral and central immune systems, as well as stress response systems such as the autonomic system and the hypothalamic–pituitary–adrenal (HPA) axis. These act in concert to alter behavior in a beneficial direction. This concept explains similar symptoms for many triggering conditions, the poorly understood pathology, and the resistance to treatment.

Somatic Symptoms: Prevalence, Co-Occurrence and Associations with Self-Perceived Health and Limitations Due To Physical Health - A Danish Population-Based Study

A high number of somatic symptoms have been associated with poor health status and increased health care use. Previous studies focused on number of symptoms without considering the specific symptoms. The aim of the study was to investigate 1) the prevalence of 19 somatic symptoms, 2) the associations between the symptoms, and 3) the associations between the somatic symptoms, self-perceived health and limitations due to physical health accounting for the co-occurrence of symptoms. Information on 19 somatic symptoms, self-perceived health and limitations due to physical health was achieved from a population-based questionnaire survey of 36,163 randomly selected adults in the Capital Region of Denmark in 2006/07. Chain graph models were used to transparently identify and describe the associations between symptoms, self-perceived health and limitations due to physical health. In total, 94.9% of the respondents were bothered by one or more of the 19 somatic symptoms. The symptoms were associated in a complex structure. Still, recognisable patterns were identified within organ systems/body parts. When accounting for symptom co-occurrence; dizziness, pain in legs, respiratory distress and tiredness were all strongly directly associated with both of the outcomes (γ>0.30). Chest pain was strongly associated with self-perceived health, and other musculoskeletal symptoms and urinary retention were strongly associated with limitations due to physical health. Other symptoms were either moderate or not statistically associated with the health status outcomes. Opposite, almost all the symptoms were strongly associated with the two outcomes when not accounting for symptom co-occurrence. In conclusion, we found that somatic symptoms were frequent and associated in a complex structure. The associations between symptoms and health status measures differed between the symptoms and depended on the co-occurrence of symptoms. This indicates an importance of considering both the specific symptoms and symptom co-occurrence in further symptom research instead of merely counting symptoms.

Collaborative stepped care for somatoform disorders: A pre-post-intervention study in primary care

OBJECTIVE

The successful management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy, and unstructured overuse of health care. This study aimed to investigate the feasibility of establishing a collaborative stepped health care network for somatoform disorders, and its impact on the diagnostic process and treatment recommendations in primary care.

METHOD

The Network for Somatoform and Functional Disorders (Sofu-Net) was established to connect 41 primary care physicians (PCP), 35 psychotherapists, and 8 mental health clinics. To evaluate Sofu-Net, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire, and were assessed in detail at the patient and PCP level. Discussion of psychosocial distress in the consultations, diagnostic detection rates and treatment recommendations were compared before and 12 months after establishing the network.

RESULTS

Out of the pre- (n=1645) and 12-months-post Sofu-Net patient samples (n=1756), 267 (16.2%) and 269 (15.3%) high-risk patients were identified. From these, 156 and 123 patients were interviewed and information was assessed from their PCP. Twelve months after Sofu-Net establishment, high-risk patients more frequently discussed psychosocial distress with their PCP (63.3% vs. 79.2%, p<.001). PCPs prescribed more antidepressants (3.8% vs. 25.2%, p<.001) and less benzodiazepines (21.8% vs. 6.5%, p<.001). Sofu-Net did not affect PCP's diagnostic detection rates or recommendation to initiate psychotherapy.

CONCLUSION

The study results indicate feasibility of an interdisciplinary network for somatoform disorders. Collaborative care networks for somatoform disorders have the potential to improve doctor-patient-communication and prescription behavior.

Bodily distress syndrome: A new diagnosis for functional disorders in primary care?

Background

Conceptualisation and classification of functional disorders appear highly inconsistent in the health-care system, particularly in primary care. Numerous terms and overlapping diagnostic criteria are prevalent of which many are considered stigmatising by general practitioners and patients. The lack of a clear concept challenges the general practitioner’s decision-making when a diagnosis or a treatment approach must be selected for a patient with a functional disorder. This calls for improvements of the diagnostic categories. Intense debate has risen in connection with the release of the fifth version of the ‘Diagnostic and Statistical Manual of Mental Disorders’ and the current revision of the ‘International Statistical Classification of Diseases and Related Health Problems’. We aim to discuss a new evidence based diagnostic proposal, bodily distress syndrome, which holds the potential to change our current approach to functional disorders in primary care. A special focus will be directed towards the validity and utility criteria recommended for diagnostic categorisation.

Discussion

A growing body of evidence suggests that the numerous diagnoses for functional disorders listed in the current classifications belong to one family of closely related disorders. We name the underlying phenomenon ‘bodily distress’; it manifests as patterns of multiple and disturbing bodily sensations. Bodily distress syndrome is a diagnostic category with specific criteria covering this illness phenomenon. The category has been explored through empirical studies, which in combination provide a sound basis for determining a symptom profile, the diagnostic stability and the boundaries of the condition. However, as bodily distress syndrome embraces only the most common symptom patterns, patients with few but impairing symptoms are not captured. Furthermore, the current lack of treatment options may also influence the acceptance of the proposed diagnosis.

Summary

Bodily distress syndrome is a diagnostic category with notable validity according to empirical studies. Nevertheless, knowledge is sparse on the utility in primary care. Future intervention studies should investigate the translation of bodily distress syndrome into clinical practice. A particular focus should be directed towards the acceptability among general practitioners and patients. Most importantly, it should be investigated whether the new category may provide the basis for better treatment and improved clinical outcome.

Perspectives on the clinical significance of functional pain syndromes in children

Functional pain syndromes (FPS) characterize a subset of individuals who experience pain and related symptoms and disability without clear structural or disease etiology. In the pediatric population, FPS hold high clinical importance due to significant prevalence rates and potential to persist into adulthood. Although extensive research has been executed to disambiguate FPS, the syndromes that fall within its spectrum remain conceptually complex and sometimes ill-defined. This paper provides an overview of available research on the classification and multifaceted etiology of FPS in youth and their effects on interpersonal, psychological, and familial function. Vital aspects of a successful multidisciplinary approach to treating this population are described; however, it is evident that future research requires more longitudinal studies.