Excessiveness in Symptom-Related Thoughts, Feelings, and Behaviors: An Investigation of Somatic Symptom Disorders in the General Population

Heart Rate Variability, Autonomic Reactivity, and Emotion Regulation during Sadness Induction in Somatic Symptom Disorder

BACKGROUND

Preliminary evidence suggests altered heart rate variability (HRV) and impaired emotion regulation (ER) in somatic symptom disorder (SSD). Moreover, HRV can be considered an index of ER. Yet, to date, research on HRV and emotional reactivity in SSD is scarce and findings are inconsistent. Thus, this study aimed to examine ER differences, HRV at rest, and in response to emotion induction in persons with SSD compared to controls.

METHODS

The sample comprised 44 persons with SSD (DSM-5; 79.5% female, Mage = 45.7, SD = 14.7) and 41 persons without SSD (non-SSD; 78% female, Mage = 44.2, SD = 14.7). We assessed the participants' somatic symptom severity, ER, and control variables (e.g., depressive symptoms). Frequency and time domain HRV by ECG and subjective emotional states were measured at rest, under sadness induction, and during recovery periods. We evaluated baseline between-group differences with t-tests, and HRV and emotional reactivity and recovery with repeated measures ANOVAs.

RESULTS

We found no significant differences in resting state HRV between persons with and without SSD. Regarding reactivity and recovery, SSD group showed lower reactivity in SDNN (standard deviation of NN interval) than non-SSD group. Moreover, SSD group reported more maladaptive ER techniques (e.g. rumination) and a higher effort to regulate their emotions during the experiment than non-SSD group.

CONCLUSIONS

The study indicated impaired ER in persons with SSD. This finding showed more clearly in self-report than in HRV. Further research on HRV reactivity including tasks evoking other negative emotions in persons with SSD is required.

Beyond borders: investigating the impact of the 2023 conflict in Gaza on generalized anxiety disorders and associated somatic symptoms and wellbeing among the Kuwait population: a global call for public intervention programs

Purpose

Armed conflicts can lead to devastating psychological health issues within and around conflict zones. Generalized anxiety disorder, associated somatic symptoms, and wellbeing were examined among the Kuwait population during the Gaza Conflict in 2023, in addition to exploring the provoking factors.

Methods

A descriptive, correlational cross-sectional design was used in this study. An online survey was conducted to collect information from people living in Kuwait during the Gaza Conflict. Data were collected between November 20 and November 27, 2023. The generalized anxiety disorder scale (GAD-7), a modified patient health questionnaire (mPHQ-15), and the World Health Organization - Five (WHO-5) were used to examine self-reported anxiety, somatic symptoms, and wellbeing among the study participants. Spearman's correlation and chi-squared tests were used to determine the relationships between anxiety, somatic symptoms, and wellbeing, and to capture the instigating factors.

Results

This study included 1979 participants living in Kuwait during the Gaza conflict period. GAD-7 and mPHQ-5 final scores were moderate (μ = 10.20 ± 4.48; μ = 11.12 ± 6.39), and WHO-5 final score was fair (μ = 53.35 ± 21.82). Spearman's correlation showed a large positive correlation between the GAD-7 and mPHQ-15, r(1977) = 0.52, p < 0.0001, a medium negative correlation between the GAD-7 and WHO-5, r(1977) = -0.36, p < 0.0001, and a medium negative correlation between the mPHQ-15 and WHO-5, r(1977) = -0.27, p < 0.0001. Spearman's correlation showed a small positive correlation between the GAD-7 and current feelings of insecurity, r(1977) = 0.246, p < 0.0001, and medium positive correlation with future fears, r(1979) = 0.292, p < 0.0001.

Conclusion

The Gaza conflict impacted the psychological health of the Kuwait population, who shared geographical, geocultural, and geopolitical factors with those in the conflict zone. A global call to address mental health intervention programs for the public in and around conflict zones is a priority.

Somatic symptom disorder symptoms in individuals at risk for heart failure: A cluster analysis with cross-sectional data from a population-based cohort study

OBJECTIVE

Identifying whether experienced symptom burden in individuals with medical predisposition indicates somatic symptom disorder (SSD) is challenging, given the high overlap in the phenomenology of symptoms within this group. This study aimed to enhance understanding SSD in individuals at risk for heart failure.

SUBJECTS AND METHODS

Cross-sectional data from the Hamburg City Health Study was analyzed including randomly selected individuals from the general population of Hamburg, Germany recruited from February 2016 to November 2018. SSD symptoms assessed with the Somatic Symptom Scale-8 and the Somatic Symptom Disorder-12 scale were categorized by applying cluster analysis including 412 individuals having at least 5% risk for heart failure-related hospitalization within the next ten years. Clusters were compared for biomedical and psychological factors using ANOVA and chi-square tests. Linear regressions, adjusting for sociodemographic, biomedical, and psychological factors, explored associations between clusters with general practitioner visits and quality of life.

RESULTS

Three clusters emerged: none (n = 215; 43% female), moderate (n = 151; 48% female), and severe (n = 46; 54% female) SSD symptom burden. The SSS-8 mean sum scores were 3.4 (SD = 2.7) for no, 6.4 (SD = 3.4) for moderate, and 12.4 (SD = 3.7) for severe SSD symptom burden. The SSD-12 mean sum scores were 3.1 (SD = 2.6) for no, 12.2 (SD = 4.2) for moderate, and 23.5 (SD = 6.7) for severe SSD symptom burden. Higher SSD symptom burden correlated with biomedical factors (having diabetes: p = .005 and dyspnea: p ≤ .001) and increased psychological burden (depression severity: p ≤ .001; anxiety severity: p ≤ .001), irrespective of heart failure risk (p = .202). Increased SSD symptoms were associated with more general practitioner visits (β = 0.172; p = .002) and decreased physical quality of life (β = -0.417; p ≤ .001).

CONCLUSION

Biomedical factors appear relevant in characterizing individuals at risk for heart failure, while psychological factors affect SSD symptom experience. Understanding SSD symptom diversity and addressing subgroup needs could prove beneficial.

Psychological risk factors of somatic symptom disorder: A systematic review and meta-analysis of cross-sectional and longitudinal studies

OBJECTIVE

Current diagnostic concepts of somatic symptom disorder (SSD) in DSM-5 and bodily distress disorder (BDD) in ICD-11 require certain psychological criteria, but researchers have called for further specification. Therefore, in a first step, this systematic review and meta-analysis aimed to summarize the current evidence on psychological factors associated with SSD/BDD and/or disorder-relevant clinical outcomes such as symptom severity and impairment.

METHODS

Psychological factors were systematically searched using Pubmed, Cochrane Library and Psycinfo via EBSCO. Studies providing original data in English or German, after 2009 were included. Cross-sectional, cohort and case-control studies investigating at least one psychological factor in individuals with SSD/BDD in the context of disorder-relevant outcomes were included.

RESULTS

Forty-three eligible studies (n = 3760 patients) in SSD (none in BDD) provided data on at least one psychological factor, 37 in case-control format, 10 cross-sectional and 5 longitudinal. Meta-analyses of the case-control studies found patients with SSD to be more impaired by depression (SMD = 1.80), anxiety (SMD = 1.55), health anxiety (SMD = 1.31) and alexithymia (SMD = 1.39), compared to healthy controls. Longitudinal results are scarce, mixed, and require refining, individual studies suggest self-concept of bodily weakness, anxiety and depression to be predictive for persistent SSD and physical functioning.

CONCLUSION

This review provides a detailed overview of the current evidence of psychological factors in relation to SSD/BDD. Future studies on SSD and BDD should include under-studied psychological factors, such as negative affect, fear avoidance, or emotion regulation. More longitudinal studies are needed to assess the predictive value of these factors.

Care trajectories of individuals with anxiety disorders: A retrospective cohort study

BACKGROUND

Anxiety disorders (ADs) are associated with increased healthcare use (HCU), and individuals may seek healthcare through various pathways according to clinical and individual characteristics. This study aimed to characterize care trajectories (CTs) of individuals with ADs.

METHODS

This is a retrospective cohort study using the Care Trajectories - Enriched Data cohort, a linkage between the Canadian Community Health Surveys (CCHS), and health administrative data from Quebec. The cohort included 5143 respondents reporting ADs to the CCHS between 2009 and 2016. We measured CTs over 5 years before CCHS using a state sequence analysis.

RESULTS

The cohort was categorized into five types of CTs. Type 1 (52.7 %) was the lowest care-seeking group, with fewer comorbidities. Type 2 (24.0 %) had higher levels of physical and mental health comorbidities and moderate HCU, mainly ambulatory visits to general practitioners. Type 3 (13.1 %) represented older patients with the highest level of physical illnesses and high HCU, predominantly ambulatory consultation of specialists other than psychiatrists. Types 4 and 5 combined young and middle-aged patients suffering from severe psychological distress. HCU of type 4 (6.7 %) was high, mainly consultations of ambulatory psychiatrists, and HCU of type 5 (3.5 %), was the highest and mostly in acute care.

LIMITATIONS

Administrative and survey data may have coding errors, missing data and self-report biases.

CONCLUSION

Five types of CTs showed distinct patterns of HCU often modulated by physical and mental health comorbidities, which emphasizes the importance of considering ADs when individuals seek care for other mental health conditions or physical illness.

Disruption of the microbiota-gut-brain axis is a defining characteristic of the α-Gal A (-/0) mouse model of Fabry disease

Fabry disease (FD) is an X-linked metabolic disease caused by a deficiency in α-galactosidase A (α-Gal A) activity. This causes accumulation of glycosphingolipids, especially globotriaosylceramide (Gb3), in different cells and organs. Neuropathic pain and gastrointestinal (GI) symptoms, such as abdominal pain, nausea, diarrhea, constipation, and early satiety, are the most frequent symptoms reported by FD patients and severely affect their quality of life. It is generally accepted that Gb3 and lyso-Gb3 are involved in the symptoms; nevertheless, the origin of these symptoms is complex and multifactorial, and the exact mechanisms of pathogenesis are still poorly understood. Here, we used a murine model of FD, the male α-Gal A (-/0) mouse, to characterize functionality, behavior, and microbiota in an attempt to elucidate the microbiota-gut-brain axis at three different ages. We provided evidence of a diarrhea-like phenotype and visceral hypersensitivity in our FD model together with reduced locomotor activity and anxiety-like behavior. We also showed for the first time that symptomology was associated with early compositional and functional dysbiosis of the gut microbiota, paralleled by alterations in fecal short-chain fatty acid levels, which partly persisted with advancing age. Interestingly, most of the dysbiotic features suggested a disruption of gut homeostasis, possibly contributing to accelerated intestinal transit, visceral hypersensitivity, and impaired communication along the gut-brain axis.

Somatic Symptom Disorder and Health Anxiety: Assessment and Management

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder (IAD) replaced the diagnostic entities of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) somatoform disorders and hypochondriasis. SSD turns away from specifying the presence or absence of a medical condition for presented symptoms and instead focuses on excessive symptom-related affects, cognitions, and behaviors. People with pathological health anxiety can be diagnosed with SSD or IAD, depending on the intensity of accompanying somatic symptoms. Cognitive-behavioral therapy shows the best empirical evidence for an effective treatment of SSD and IAD.

Efficacy of Heart Rate Variability Biofeedback for Somatic Symptom Disorder: A Pilot Randomized Controlled Trial

OBJECTIVE

Patients with somatic symptom disorder (SSD) often receive targeted intervention only after a long duration of illness. Moreover, the reported effect sizes of interventions for SSD are small. Therefore, improvement and evaluation of interventions are needed. Preliminary evidence suggests autonomic imbalance, for example, lower heart rate variability (HRV) in SSD. HRV biofeedback (HRV-BF) as a method for self-regulation shows initial positive effects in chronic pain and functional syndromes. The aim of this study was to evaluate the efficacy of a brief HRV-BF intervention for SSD.

METHODS

Of a total of 50 participants with SSD ( Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ) who were recruited and randomly assigned to four sessions of HRV-BF ( n = 25) or autogenic training (AT; n = 25), 49 participants were analyzed (female, 77.6%; mean [standard deviation] age = 45.3 [14.4] years). The primary outcomes were somatic symptom severity (Screening for Somatoform Disorders, numeric rating scale) and HRV. Secondary outcomes were psychological characteristics of SSD (e.g., the Somatic Symptom Disorder 12 scale, health concerns, emotion regulation). The data were collected before and after intervention and were analyzed with repeated-measures analyses of variance and post hoc t tests.

RESULTS

Symptom severity improved after both, HRV-BF and AT. Standard Deviation of the NN Interval and psychological symptoms improved significantly more strongly in the HRV-BF than in the AT group (e.g., Standard Deviation of the NN Interval: ηp2 interaction = 0.10, p = .047).

CONCLUSIONS

The improvements in somatic symptoms, but specifically in cognitive-affective symptoms and autonomic regulation, suggest that HRV-BF with only four sessions is a potentially useful intervention option for SSD. Thus, adding this short HRV-BF intervention to existing psychological treatments for SSD may be promising.Trial Registration : German Clinical Trial Register identifier DRKS00017099 ( https://www.drks.de ).

Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders

Somatic symptoms which are not fully explained by a medical condition (medically unexplained symptoms) have a high relevance for the public health. They are very common both in the general population and in patients in health care, and may develop into chronic impairing conditions such as somatoform disorders. In recent years, the relevance of specific negative psychological factors for the diagnosis and the stability of somatoform disorders and for the impairment by medically unexplained symptoms gained more and more attention. This resulted-among others- in core changes in the diagnostic classification criteria of somatoform disorders. Against this background, the present "Perspective" will outline recent developments and findings in the area of medically unexplained somatic symptoms and somatoform disorders. Moreover, it will lay a special focus on evidence on specific negative psychological factors that may influence the course of unexplained somatic symptoms and disorders and the impairment caused by these symptoms.

A unified Internet-delivered exposure treatment for undifferentiated somatic symptom disorder: single-group prospective feasibility trial

BACKGROUND

Exposure-based psychological treatment appears to have beneficial effects for several patient groups that commonly report distress related to persistent somatic symptoms. Yet exposure-based treatment is rarely offered in routine care. This may be because existing treatment protocols have been developed for specific symptom clusters or specific unwanted responses to somatic symptoms, and many clinics do not have the resources to offer all these specialised treatments in parallel. In preparation for a randomised controlled trial, we investigated the feasibility of a new and unified Internet-delivered exposure treatment (OSF.io: cnbwj) for somatic symptom disorder regardless of somatic symptom domain (e.g. cardiopulmonary, fatigue, gastrointestinal, pain), combination of unwanted emotions (e.g. anger, anxiety, fear, shame) and whether somatic symptoms are medically explained or not. We hypothesised that a wide spectrum of subgroups would show interest, that the treatment would be rated as credible, that adherence would be adequate, that the measurement strategy would be acceptable and that there would be no serious adverse events.

METHODS

Single-group prospective cohort study where 33 self-referred adults with undifferentiated DSM-5 somatic symptom disorder took part in 8 weeks of unified Internet-delivered exposure treatment delivered via a web platform hosted by a medical university. Self-report questionnaires were administered online before treatment, each week during treatment, post treatment and 3 months after treatment.

RESULTS

Participants reported a broad spectrum of symptoms. The Credibility/Expectancy mean score was 34.5 (SD = 7.0, range: 18-47). Participants completed 91% (150/165) of all modules and 97% of the participants (32/33) completed at least two exposure exercises. The average participant rated the adequacy of the rationale as 8.4 (SD = 1.5) on a scale from 0 to 10. The post-treatment assessment was completed by 97% (32/33), and 84% (27/32) rated the measurement strategy as acceptable. The Client Satisfaction Questionnaire mean score was 25.3 (SD = 4.7, range: 17-32) and no serious adverse events were reported. Reductions in subjective somatic symptom burden (the Patient Health Questionnaire 15; d = 0.90) and symptom preoccupation (the somatic symptom disorder 12; d = 1.17) were large and sustained.

CONCLUSIONS

Delivering a unified Internet-delivered exposure-based treatment protocol for individuals with undifferentiated somatic symptom disorder appears to be feasible.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04511286 . Registered on August 13, 2020.

Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis

BACKGROUND

In 2013, the diagnosis of somatic symptom disorder (SSD) was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This review aims to comprehensively synthesize contemporary evidence related to SSD.

METHODS

A scoping review was conducted using PubMed, PsycINFO, and Cochrane Library. The main inclusion criteria were SSD and publication in the English language between 01/2009 and 05/2020. Systematic search terms also included subheadings for the DSM-5 text sections; i.e., diagnostic features, prevalence, development and course, risk and prognostic factors, culture, gender, suicide risk, functional consequences, differential diagnosis, and comorbidity.

RESULTS

Eight hundred and eighty-two articles were identified, of which 59 full texts were included for analysis. Empirical evidence supports the reliability, validity, and clinical utility of SSD diagnostic criteria, but the further specification of the psychological SSD B-criteria criteria seems necessary. General population studies using self-report questionnaires reported mean frequencies for SSD of 12.9% [95% confidence interval (CI) 12.5-13.3%], while prevalence studies based on criterion standard interviews are lacking. SSD was associated with increased functional impairment, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Relevant research gaps remain regarding developmental aspects, risk and prognostic factors, suicide risk as well as culture- and gender-associated issues.

CONCLUSIONS

Strengths of the SSD diagnosis are its good reliability, validity, and clinical utility, which substantially improved on its predecessors. SSD characterizes a specific patient population that is significantly impaired both physically and psychologically. However, substantial research gaps exist, e.g., regarding SSD prevalence assessed with criterion standard diagnostic interviews.

Affective and cognitive theory of mind in posttraumatic stress, major depressive, and somatic symptom disorders: Association with childhood trauma

OBJECTIVES

Childhood trauma constitutes a major risk factor for adult psychopathology, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and somatic symptom disorder (SSD). One potential mechanism linking childhood trauma to adult psychopathology may be alterations in theory of mind (ToM). Given the lack of transdiagnostic studies on the association between childhood trauma and ToM, further research is needed to elucidate whether and how childhood trauma relates to ToM impairments across and within diagnostic boundaries.

DESIGN

A cross-sectional study design was applied.

METHODS

A total of 137 individuals with varying levels of childhood trauma took part in this study, encompassing individuals with PTSD (n = 33), MDD (n = 33), SSD (n = 36), and healthy volunteers (HVs; n = 35). To assess ToM performance and childhood trauma, the Movie for the Assessment of Social Cognition was administered along with the Childhood Trauma Questionnaire.

RESULTS

Only individuals with PTSD, but not individuals with MDD or SSD, showed a worse ToM performance compared to HVs. In the whole sample, childhood trauma correlated negatively with ToM performance. Exploratory group-specific analyses revealed higher levels of childhood trauma to be associated with more excessive ToM errors in individuals with SSD, and notably with an enhanced ToM performance in individuals with MDD.

CONCLUSIONS

Our results indicate associations between childhood trauma and ToM impairments in a large, transdiagnostic sample. Provided replication in future studies, our findings suggest ToM capacities as a promising treatment target for individuals exposed to severe childhood trauma, at least or particularly with a diagnosis of PTSD.

PRACTITIONER POINTS

Our results suggest that individuals with a history of severe childhood trauma, at least or particularly with a clinical diagnosis of posttraumatic stress disorder, may benefit from therapeutic approaches targeting theory of mind capacities. Our findings indicate that higher levels of childhood trauma may be linked to a specific 'hypermentalizing' bias in somatic symptom disorder. Our findings further point towards an association between higher levels of childhood trauma and a heightened - rather than a diminished - sensitivity towards interpersonal cues in major depressive disorder. Provided further confirmatory evidence, our findings may support diagnosis-specific approaches in ameliorating theory of mind abilities in individuals with different mental disorders and a history of severe childhood trauma.