Somatoform disorder in a psychiatric setting. Systematic comparisons with depression and anxiety disorders

Neurasthenia and the Social Construction of Psychiatric Knowledge

The diagnostic category of neurasthenia is examined as a cultural construct with social uses and implications for psychiatric nosologies. The legitimation of otherwise stigmatized symptoms through a diagnosis of neuras thenia is discussed. The re-thinking and re-definition of the category in Chinese psychiatry in the 1980s is reviewed to illustrate the social construction of knowl edge and DSM's influence abroad. The proposal to include neurasthenia in DSM-IV is considered as part of the initiative to increase the cultural validity of the DSM system. Implications for research are suggested, and questions raised about the ability of DSM to resist change and re-produce itself.

Cognitive behavioral therapy for somatoform disorders

Patients presenting with somatoform disorders often incur excessive health care charges and fail to respond to standard treatment. The purpose of this article is to provide an overview of the diagnostic criteria and demographic and clinical characteristics of each somatoform disorder and to examine the research assessing the efficacy of cognitive behavioral therapy (CBT) for each disorder. The review shows that CBT has received some empirical support for somatization, hypochondriasis, and body dysmorphic disorder. However, there are few data on the impact of treatment on health care use, especially when the cost of CBT is factored into the equation. Too few methodologically sound studies have been published on the treatment of conversion disorder or of pain disorder to make any conclusions.

Somatoform disorders: comorbidity with other DSM-III-R psychiatric diagnoses in Greece

From a total sample of 1,448 psychiatric outpatients, 175 (12.1%) received a diagnosis of a somatoform disorder according to DSM-III-R criteria. One hundred twenty-two (70%) of these patients had another current axis I diagnosis, and this rate increased to 79% (139 of 175) when lifetime psychiatric diagnoses were recorded. The most frequent comorbid diagnoses were depressive disorders, i.e., dysthymia and major depression, and then anxiety disorders, mainly panic disorder. One hundred ten (63%) of the somatoform patients met the criteria for a personality disorder, significantly higher than the rate (52%) for the rest of the total sample (n = 1,273), who were used as a control group. The most frequent comorbid personality disorders were histrionic, dependent, and personalities of cluster B in general. Hypochondriasis was the only somatoform disorder that was additionally significantly related to obsessive-compulsive personality disorder. Somatoform patients with a concomitant personality disorder manifested more severe overall psychopathology as measured by the Minnesota Multiphasic Personality Inventory (MMPI) and a worse level of functioning than those without. The results of the present study show that (1) patients with somatoform disorders have a high rate of comorbidity with other clinical syndromes and personality disorders, and (2) the presence of a personality disorder is related to more severe overall psychopathology and a worse level of functioning. All of the above indicate that special attention must be paid to the interaction between somatoform disorders, other clinical syndromes, and personality structure at the level of both clinical and research practice.

Cultural dimensions of psychiatric diagnosis. A comparison of DSM-III-R and illness explanatory models in south India

BACKGROUND

Cross-cultural research to examine the cultural validity of diagnostic categories and underlying concepts requires methods that integrate epidemiological and anthropological frameworks.

METHOD

The Explanatory Model Interview Catalogue (EMIC) and Structured Clinical Interview for DSM-III-R (SCID) were used to study 80 psychiatric out-patients with depressive neurosis at a clinic in south India.

RESULTS

Summary kappa values of 0.75 for the EMIC and 0.68 for the SCID confirmed interrater reliability. Comparison of patient explanatory models and SCID diagnoses showed that patients emphasised somatic experience while clinicians emphasised depressive diagnoses. More than half the patients (55%) received a non-specific or dual diagnosis.

CONCLUSIONS

These findings raise questions about the distinctiveness of depressive, anxiety, and somatoform (DAS) disorders for this population.

Somatization in children and adolescents

OBJECTIVE

To review the empirical literature on somatization in the pediatric age group, emphasizing prevalence, influence on health care utilization, issues in the development of somatization, comorbidity with other psychiatric disorders, assessment, and treatment.

METHOD

One hundred nineteen studies and reports addressing medically unexplained somatic symptoms in children and adolescents were compiled via MEDLINE search and extensive cross-referencing. All available controlled studies were included, as were selected case reports and collections of cases. Selected citations from the adult literature were chosen for relevance to pediatric somatization.

RESULTS

Recurrent, medically unexplained physical symptoms are common in the pediatric age group, are often associated with other psychiatric symptoms, and may represent a common presentation of psychiatric disorder in the primary care setting. DSM-III-R-defined somatization disorder is rare, and pseudoneurological symptoms are unusual. Patients may be at risk for potentially dangerous, costly, and unnecessary medical investigations and treatments, and they may excessively utilize health care services.

CONCLUSION

Our current understanding of pediatric somatization and its consequences is limited. Collaboration between mental health professionals and primary health care providers is essential. Consistent terminology, developmentally appropriate classification, and systematic future research will be necessary for the development of successful prevention and treatment strategies.

Witchcraft-explained childhood tragedies in Tlaxcala, and their medical sequelae

This paper describes results of a study in Tlaxcala, Mexico, involving the sudden death of infants and children that culturally are explained as resulting from the attack of blood-sucking witches. The attacks of the supernaturals are relatively common occurrences and an elaborate ideology has evolved to explain them. Such an ideology serves to explain what constitutes a major trauma of loss and supernatural assault. Data on a total of 47 cases were collected prospectively. The illness experiences of the parents following these traumas were recorded and their nature and consequences analyzed. The results of the study provide a 'folk medical' epidemiology of sudden infant death, a well identified cultural-ecological stressor. Ideas from cultural, psychological and medical anthropology as well as general medicine and psychiatry are used in the interpretation of the results.

Lifetime diagnoses in patients with somatoform disorders: which came first?

Thirty inpatients with somatoform disorders were examined with the structured clinical interview SCID for psychiatric lifetime diagnosis. In the present diagnoses, we found a concordance of 63% for somatoform and affective disorders and the lifetime comorbidity of both disorders was 87%. Additionally, patients with somatoform disorders frequently had a history of other psychiatric disorders (for example, anxiety disorders, 40%). For 73% of patients with somatoform disorders and a history of affective disorders, the onset of the somatoform disorder was prior to the onset of another psychiatric disorder. The time interval between the onsets of somatoform disorders and affective disorders was greater than 1 year for most patients; for 46% of the patients with a history of both disorders, the time interval between the two disorders was more than 5 years. The course of illness for somatoform and affective disorders was quite different; while affective disorders tended to episodic periods with interim remissions, the somatoform disorders usually showed long, chronic courses (mean duration of the current somatoform disorder was 11.9 years). Finally, the Symptom Check List SCL-90R demonstrated good discrimination between patients with affective and anxiety disorders. However, the SCL-90R failed to discriminate patients with somatoform disorders from affective- and anxiety-disordered subjects. Therefore, the development of other psychometric scales is necessary for the evaluation of patients with somatoform disorders.

Somatization and depression

The majority of depressed patients complaining of physical symptoms first present to general practitioners. This article reviews the frequency of association between somatization and depression and the links between them. The need to prevent persistent somatization is emphasized.

Somatoform disorders in the general hospital inpatient setting

The somatoform disorders present dilemmas on acute inpatient medical/surgical services because they may closely mimic authentic physical illness and result in misapplied medical treatment. However, there have been few diagnostic studies of this important group in the medical/surgical inpatient setting. Inpatient psychiatric consultations at Mount Sinai Medical Center during 1980-1987 were recorded using a 384-item computerized data base protocol. DSM-III somatoform disorders were identified in 33 of 1801 initial consultations (1.8%) and in 35 of 1363 at time of termination (2.6%); demographic and diagnostic characteristics of somatoforms and others were compared. The question of a psychogenic component to the illness and problem with pain management were the most common stated reasons for consultation. Somatoform patients were more likely than others to be female (p less than 0.05), Hispanic (p less than 0.05), and to have Axis II comorbidity (p less than 0.001). Axis III comorbidity was present in 94%. Thirty-one percent of patients diagnosed as somatoform on final follow-up assessment had not been diagnosable as somatoform on initial assessment. The findings emphasize the necessity of ongoing assessment in improving diagnostic certainty, as well as the prevalence and importance of medical comorbidity among patients with somatoform disorders in this setting.