Why do some psychiatric patients somatize?

Somatoform pain: a developmental theory and translational research review

Somatoform pain is a highly prevalent, debilitating condition and a tremendous public health problem. Effective treatments for somatoform pain are urgently needed. The etiology of this condition is, however, still unknown. On the basis of a review of recent basic and clinical research, we propose one potential mechanism of symptom formation in somatoform pain and a developmental theory of its pathogenesis. Emerging evidence from animal and human studies in developmental neurobiology, cognitive-affective neuroscience, psychoneuroimmunology, genetics, and epigenetics, as well as that from clinical and treatment studies on somatoform pain, points to the existence of a shared neural system that underlies physical and social pain. Research findings also show that nonoptimal early experiences interact with genetic predispositions to influence the development of this shared system and the ability to regulate it effectively. Interpersonal affect regulation between infant and caregiver is crucial for the optimal development of these brain circuits. The aberrant development of this shared neural system during infancy, childhood, and adolescence may therefore ultimately lead to an increased sensitivity to physical and social pain and to problems with their regulation in adulthood. The authors critically review translational research findings that support this theory and discuss its clinical and research implications. Specifically, the proposed theory and research review suggest that psychotherapeutic and/or pharmacological interventions that foster the development of affect regulation capacities in an interpersonal context will also serve to more effectively modulate aberrantly activated neural pain circuits and thus be of particular benefit for the treatment of somatoform pain.

Changes in patterns of psychiatric referral in a German general hospital: results of a comparison of two 1-year surveys 8 years apart

The aim of this study was to investigate the issues of changes in patterns of referral and interventions and of consistency of psychiatric diagnoses assigned by a psychiatric consultation-liaison service in a general hospital over an 8-year period. We compared two 1-year surveys 8 years apart. Survey A comprised 713 referrals in 1990, and Survey B included 1025 consecutive new consultations in 1998. Data pertained to demographic characteristics, source of referral, reason for referral, psychiatric diagnosis according to DSM-III-R, and intervention. Our study demonstrated significant changes in diagnostic characteristics and in patterns of referral and intervention over the years. Changes in source of referral and psychiatric diagnoses were associated with the increasing involvement of clinical psychologists and specialists in psychosomatic medicine. Also, surgeons and physicians were increasingly aware of psychiatric morbidity in medical-surgical populations. Modern psychopharmacological treatment approaches resulted in a higher rate of recommendation of psychotropic medication. To ameliorate the provision of psychiatric care for general hospital patients, the need for a biopsychosocial conceptual framework at the interface of psychiatry and medicine in general hospitals should be underscored.

Personality disorders in problematic medical patients

To better understand problematic medical patients, the psychiatric diagnoses of 448 patients referred to a behavioral medicine clinic were examined. Forty-two percent met DSM-III-R personality disorder criteria. Analysis of the comorbidity of Axis I and Axis II diagnoses revealed a statistically significant co-occurrence between somatoform and personality disorders (P < 0.0001). Some of the difficulties in making a personality disorder diagnosis are reviewed, as are reasons why knowledge of personality disorder diagnoses is important to medical providers.

Perception of problems in psychiatric inpatients: denial, race and service usage

The importance of the ways in which people with psychiatric problems construe their difficulties is considered in this study. A study of 60 consecutive acute admissions to wards serving an inner city area in London (UK) is reported. The results indicated that 55.8% of the sample did not consider themselves to have psychiatric problems: 15.4% said that they had no problems at all and 40.4% thought they had physical or social problems rather than psychiatric ones. Although more younger people denied that they had problems and none of those who denied having problems sought the help of a general practitioner, there was a significant association between diagnosis and perception of problems, and when this was taken into account these associations disappeared. Of those who denied having any problems, only one person had no police involvement on admission. Significantly more of those who denied problems were compulsorily admitted and there were significant differences in the proportions of whites and African-Caribbeans reporting different types of problems. African-Caribbeans were both more likely to consider that they had no problems at all and to be compulsorily admitted. Although African-Caribbeans were also more likely to be diagnosed as experiencing psychotic disorders, it was their ethnic status rather than their diagnostic category that determined both their status on admission and the way in which they construed their problems. Denial among whites tended to take the form of somatisation or construction of problems in terms of social difficulties.

The management of chronic somatisation

'Somatisation' is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied. In some patients this process becomes chronic (in excess of six months). Special skills and strategies are required by non-psychiatrists to manage these patients, for whom the acceptance of psychiatric treatment should be facilitated. When taking the history, doctors should be aware of psychosocial cues; thereafter they should be consistent and unambiguous in their management. An agenda should be set early on, with limits on investigations. Failure to manage this group of patients is costly, and further intervention studies are required not only to reduce health service and other costs, but also to relieve the non-monetary burden of physical and psychosocial disability on patients and their relatives.

Screening for psychiatric symptoms and illness behaviour in a pain clinic

Evolution of a multidisciplinary pain clinic in a rehabilitation hospital is described. The assessment process was facilitated, particularly with respect to psychiatric and psychological evaluation, by the preliminary administration of two well established but simple self-administered questionnaire instruments, the Illness Behaviour Questionnaire (IBQ) and the Crown-Crisp Experiential Index (CCEI). The characteristics of our pain clinic population are described. They demonstrate questionnaire profiles which are typical of pain patients. Attention is drawn to the CCEI profile now shown in three studies of pain patients, predominance of the somatic anxiety (S) scale occurring in all. Correlations between the IBQ and CCEI showed, inter alia, that the S scale is a measure of somatisation in pain patients. This paper aims to describe the changes in the clinic since previously published descriptions, to note the characteristics of our patient on the questionnaire instruments and to comment on the value of these questionnaires in the assessment of psychiatric symptoms and somatisation in pain clinic patients.

Palestinian martyr widowhood--emotional needs in conflict with role expectations?

The phenomenon of martyrdom is described in the context of the Palestinian struggle, with emphasis on its implications at the psychosocial level. The situation of the martyr widows is discussed, with highlight on their difficult double role as mourning individuals under the pressure of social, religious, and political expectations.

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.

Delusion of parasitosis or chronic tactile hallucinosis: hypothesis about their brain physiopathology

The abnormal belief of having the skin infested by parasites is a syndrome with different etiologies. Approximately 12% of cases are induced by another patient with the same syndrome. In noninduced cases, two physiopathological brain mechanisms have been proposed: a delusion, or a primary abnormal tactile sensation with a secondary delusional elaboration. These two hypotheses have been characterized by Berrios as cognitive and sensorialist approaches, respectively. Although modern literature defines this syndrome as a delusion, early literature, particularly German, described both approaches, and even emphasized the sensorialist approach, classifying it as a chronic tactile hallucinosis. A thorough review of the literature suggests both mechanisms may be possible.

The nonspecific symptom screening method. Detection of nonpsychotic morbidity based on nonspecific symptoms

Detection of nonpsychotic morbidity in primary care patients presenting with nonspecific and somatic symptoms has been difficult because of several factors related to the patients, primary care clinicians, and working conditions of the over-crowded clinic. The available standardized screening questionnaires do not overcome many of these difficulties when used for routine clinical purposes. A screening method based only on nonspecific symptoms, which could be easily incorporated into the routine initial clinical work-up of a patient, was developed in this study and has been found to have good validity and reliability for screening nonpsychotic morbidity. The method of construction of the screen and its clinical applicability and limitations are discussed.

Psychiatric morbidity among mothers attending well-baby clinic: a cross-cultural comparison

The Self Reporting Questionnaire (SRQ), a screening instrument developed for psychiatric disorders in developing countries, was administered to 149 mothers, half of whom where non-white, attending a well-baby clinic in Manchester, United Kingdom. Psychiatric interview confirmed that high scorers on the SRQ could be given DSM-III diagnoses of anxiety and depression, but the cut-off point on SRQ for being a definite psychiatric case was found to be 7/8, higher than previous validation studies. This was the same for Asians as well as white mothers. Comparison of somatic versus psychological scores between Asian and white mothers showed no significant difference across the range of total SRQ scores. Over half of the mothers who were psychiatric cases were attending their doctors and all the Asian women doing so were attending for somatic symptoms. This study suggests that when measured in a well-baby clinic, somatic and psychological symptoms are reported equally frequently by white and Asian immigrant women in the United Kingdom but somatic symptoms predominate when Asian women consult a doctor.

Dysmorphophobia: body dysmorphic disorder or delusional disorder, somatic subtype?

The DSM-III-R proposes to divide dysmorphophobia into two separate disorders: delusional disorder, somatic subtype and dysmorphic disorder. We believe that this distinction of delusional and nondelusional is impossible from a phenomenological point of view, and that dysmorphophobic beliefs are better classified as overvalued ideas. The concept of dysmorphophobia and its relationship to monosymptomatic hypochondriacal psychoses and DSM-III-R categories is reviewed. A case report is described to support these arguments.

Pain in non-psychotic psychiatric patients: life events, symptomatology and personality traits

Occurrence of pain was investigated in 73 non-psychotic psychiatric inpatients; 75% had been bothered by pain within the last 3 months and about half of these had pain every day. Pain was most frequent in patients with neurosis and personality disorder. The occurrence of pain was significantly associated with unskilled work, but was not related to experience of social stress. Patients with pain reported more anxiety and hostile feelings and had a higher degree of somatic anxiety and muscular tension, thus attaching importance to anxiety-induced muscle spasm as a pain-mediating mechanism. A specific relationship between pain and depression was not supported.