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Painting the picture of distressing somatic symptoms
Journal of Psychosomatic Research 68 (2010) 1 – 3
Editorials
Painting the picture of distressing somatic symptoms Somatoform disorders are not only one of the most prevalent clinical conditions described in DSM-IV/ICD-10 section F but also one of the most neglected and scientifically understudied conditions. Many researchers have been reluctant to study these medically unexplained somatic symptoms, and despite their epidemiological relevance, in some large-scaled epidemiological surveys these conditions were even not considered (e.g., National Comorbidity Survey). Therefore, it is exciting to read in this issue of Journal of Psychosomatic Research how more and more pieces of the puzzle of medically unexplained symptoms are identified. Meanwhile, it seems obvious that these somatic syndromes should be distinguished from anxiety and depressive syndromes. Moreover, different functional somatic syndromes seem to share common features, and they also share differences to other psychiatric disorders. They have a unique course and outcome, and treatment responsiveness is different from other DSM categories. This offers the basis for a clear definition of boundaries, and a clear description of a disorder is a necessary precondition for the validity of its classification criteria [1–3]. A further step in the validation of classification criteria is to show that the disorder of interests (e.g., somatic symptom disorder) has different predictors for persistence than other disorders such as anxiety and depression. McKenzie et al. (in this issue) are able to distinguish the predictors for these three groups, which is an additional confirmation of the necessity of a discrete diagnosis for disabling somatic symptoms [4]. The diagnostic criteria can be considered to be the frame of the picture of distressing somatic symptoms. The current discussion of the DSM-V proposal that has been published in a recent issue of this journal [5] shows a radical change to former approaches of classifying this syndrome. The prototype of somatoform disorders (“somatization disorder”) has been criticized as being overexclusive and employs poorly founded cutoff scores of number of somatic symptoms. The radical change of the new proposal is that number of symptoms plays only a minor role while the distress of symptoms associated with psychological features and symptom consequences are emphasized. Therefore, it can be expected that this new proposal identifies more of the patients who suffer from unclear somatic symptoms and who 0022-3999/09/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2009.11.001
present these symptoms in primary care and specialist offices. Defining such a somatic symptom disorder in DSM-V (or accordingly in Section F of ICD-10/11) requires not only the identification of somatic symptoms, but also specifying associated psychological features. This step was more than necessary to justify the classification as a DSM/ ICD Section F diagnosis. Therefore, the new proposal is a huge step forward. However, it also has to be discussed whether the presented proposal is the best that can be achieved or whether it is still possible to improve it. This discussion starts with several letters to the editor in this issue. Schröder and Fink state that it is problematic to include health care characteristics as classification criteria (e.g., health care utilization, physicians' miscontent, lacking reassurance of physicians' report) [6]. A century ago, people with tuberculosis have been considered to be treatment-resistant and costly, and they were sent for months or years to Swiss sanatoriums. However, this was not the fault of the patient, but the lacking knowledge of the experts. Why are patients with somatoform disorder described as being unresponsive to therapies [5]? Is it the patients' fault that medicine cannot offer effective interventions for them? Antidepressant treatment has been shown to work less effectively in terms of somatic symptoms than in terms of depressive affect [7–9]. Cognitive behavioral therapy, the best evaluated psychological intervention, shows moderate effectiveness in somatization syndrome compared to panic disorder or mild to moderate depressive disorders [10,11]. The classification approach has to be very careful in not blaming the patients for the helplessness of the experts. Considering the fact that many patients are seriously suffering from the symptoms, it is not surprising that they seek medical help until they feel relieved from their pains. Therefore, the major need is improved medical care and more powerful interventions. The article of Rosenzweig et al. [12] (in this issue) is highly relevant because it points to potentially new interventions. From a scientific point of view, it would be even more helpful to develop new therapies that integrate current findings for this patient group more rigorously. Many new concepts such as emotion regulation deficit, but also the results on the role of stress and others could be better integrated in current treatment approaches.
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Editorials / Journal of Psychosomatic Research 68 (2010) 1–3
One basic assumption of many experts is that patients with somatic syndromes have a limited and inflexible organic causality model. Again, this seems to be more and more a result of what is problematic for the doctor but less of what is in the head of the patient. As Hiller et al. [13] confirmed (in this issue), patients with multiple somatic symptoms are fully able to consider psychological causes for their complaints, such as stress, conflicts and others. This has already been shown in former studies [14] and is confirmed with the semi-structured interview of Hiller et al. that might be more acceptable for some patients. In fact, the problematic patient is not only the one expressing primarily organic illness attributions but also the additional consideration of psychological causes is usually associated with comorbid depression. This points to the fact that treatment approaches should not try to reattribute patient's organic causal explanations to psychological causal explanations but should support the patient to make adequate use of the different illness attributions that are already in his or her mind. This is a great example how research of mechanisms and associated features could influence treatment planning. Further points of the new proposal for somatic symptom disorder have to be discussed in the upcoming months. The elimination of health anxiety/hypochondriasis is a serious point (again, see letter of Schröder and Fink in this issue). Health anxiety plays an important role in many medical conditions and can be a disorder of its own. It certainly has to be distinguished from somatic symptom disorder because anxiety is the major mechanism, the course of health anxiety is more fluctuating than the course of chronic somatic symptom disorder, and other mechanisms seem to be different. For patients with chronic organic conditions and increased health anxiety, it would be helpful to have a comorbid diagnosis that reflects patients' fears and subsequent problems even in the absence of other criteria of somatic symptom disorder. Current classification approaches have to be modified because they are overexclusive, but health anxiety seems still to be a discrete problem. Moreover, the current proposal for DSM-V does not address the issue of chronic pain conditions. Unfortunately, experts of psychosomatic medicine and experts of pain research are only rarely interacting. However, pain symptoms are the most frequent somatic symptoms, and there is a huge field of research and clinical practice that is specialized on pain. Many pain experts would prefer to have a specific pain diagnosis under DSM/ICD Section F to describe those patients with verified or supposed organic conditions that do not fully explain the severity or persistence of pain. It is unclear whether all of these patients should receive the diagnosis of chronic somatic symptom disorder or whether it is helpful to have a unique diagnosis for pain disorder under this category. Finally, the problem of finding an adequate name for this diagnosis is still unsolved. The current term somatoform is criticized because some health care professionals associate it with a psychological origin of symptoms. However, evidence is low that introducing a completely new term
avoids misinterpretation of its content. In fact, introducing a new term is a step backward because initiatives have to be restarted to introduce it, to increase its popularity, to describe it to other specialists, and to encourage them to use it. However, this is the basis for adequate care. Only a clear long-term perspective of being advantageous justifies these short-term disadvantages of introducing a new label. Therefore, it is not surprising that Creed et al. [15] (in this issue) report expert agreement that it might be easier to revitalize one of the already existing terms instead of introducing a completely new term. Moreover, the new label “somatic symptom disorder” does not seem to be unequivocally accepted; in contrast, several points of critique are already formulated especially from non-US countries (see Creed et al., in this issue). The confusion of the term symptom with disorder in a diagnosis might be a problem for people who prefer conceptual clarity. Moreover, what about “anxiety symptom disorder” or “bulimia symptom disorder”? This construction of terms might soon be associated with “reporting symptoms of type A, although in reality the patient suffers from disorder B.” Then, we are back to the problems we have with the current term somatoform. The discussion about an adequate name for the disorder can go on … This issue of the Journal of Psychosomatic Research shows that the knowledge on somatic symptoms is progressing, and more and more of the picture is drawn. The interaction of somatic experiences and psychological features (see, e.g., the papers of Delaroca-Chiapas et al. or Carney et al. in this issue) is crucial for the understanding of symptom development and symptom maintenance [16,17]. The investigation of symptom course starting from a single, acute symptom experience and ending with chronic conditions with comorbid depression and social withdrawal further increases the understanding of this condition (see Deary et al. in this paper [18]. More powerful treatments are necessary, and we should also think about prevention programs. Much could be achieved during the last years, but there is still much to do.
Winfried Rief Department of Psychology University of Marburg Marburg, Germany San Diego, USA E-mail address: [email protected] References [1] Guze SB. The validity and significance of the clinical diagnosis of hysteria (Briquet's syndrome). Am J Psychiatry 1975;132:138–41. [2] Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003;160:4–12. [3] Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatr 1970;126: 107–11.
Editorials / Journal of Psychosomatic Research 68 (2010) 1–3 [4] McKenzie M, Clarke DM, McKenzie DP, Smith GC. Which factors predict the persistence of DSM-IV depression anxiety, and somatoform disorder in the medically ill three months post hospital discharge? J Psychosom Res 2010;68:21–8. [5] Dimsdale J, Creed F. The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV—a preliminary report. J Psychosom Res 2009;66:473–6. [6] Schroeder A, Fink P. The proposed diagnosis of somatic symptom disorders in DSM-V: two steps forward and one step back? J Psychosom Res 2010;68:95–6. [7] Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Psychosom Med 1998;60:503–9. [8] Papakostas GI, Petersen T, Denninger J, Sonawalla SB, Mahal Y, Alpert JE, et al. Somatic symptoms in treatment-resistant depression. Psychiatry Res 2003;118:39–45. [9] Papakostas GI, Petersen T, Hughes ME, Nierenberg AA, Alpert JE, Fava M. Anxiety and somatic symptoms as predictors of treatmentrelated adverse events in major depressive disorder. Psychiatry Res 2004;126:287–90. [10] Allen LA, Escobar JI, Lehrer PM, Gara MA, Woolfolk RL. Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature. Psychosom Med 2002;64:939–50. [11] Looper KJ, Kirmayer LJ. Behavioral medicine approaches to somatoform disorders. J Consult Clin Psychol 2002;70:810–27.
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[12] Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D. Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. J Psychosom Res 2010;68:29–36. [13] Hiller W, Cebulla M, Korn H-J, Leibbrand R, Röers B, Nilges P. Causal symptom attributions in somatoform disorder and chronic pain. J Psychosom Res 2010;68:9–19. [14] Rief W, Nanke A, Emmerich J, Bender A, Zech T. Causal illness attributions in somatoform disorders—associations with comorbidity and illness behavior. J Psychosom Res 2004;57:367–71. [15] Creed F, Fink P, Guthrie E, Henningsen P, Rief W, Sharpe M, et al. Is there a better term than “Medically unexplained symptoms”? J Psychosom Res 2010;68:5–8. [16] De la Roca-Chiapas JM, Solís-Ortiz S, Fajardo-Araujo M, Sosa M, Córdova-Fraga T, Rosa-Zarate A. Stress profile, coping style, anxiety, depression and gastric emptying as predictors of the functional dyspepsia: a case-control study. J Psychosom Res 2010; 68:73–81. [17] Carney CE, Edinger JD, Morin CM, Manber R, Rybarczyk B, Stepanski EJ, et al. Examining maladaptive beliefs about sleep across insomnia patient groups. J Psychosom Res 2010;68:57–65. [18] Deary I, Wilson J, Carding P, MacKenzie K, Watson R. From dysphonia to dysphoria: Mokken scaling shows a strong, reliable hierarchy of voice symptoms in the Voice Symptom Scale questionnaire. J Psychosom Res 2010;68:67–71.
Editorials
Painting the picture of distressing somatic symptoms Somatoform disorders are not only one of the most prevalent clinical conditions described in DSM-IV/ICD-10 section F but also one of the most neglected and scientifically understudied conditions. Many researchers have been reluctant to study these medically unexplained somatic symptoms, and despite their epidemiological relevance, in some large-scaled epidemiological surveys these conditions were even not considered (e.g., National Comorbidity Survey). Therefore, it is exciting to read in this issue of Journal of Psychosomatic Research how more and more pieces of the puzzle of medically unexplained symptoms are identified. Meanwhile, it seems obvious that these somatic syndromes should be distinguished from anxiety and depressive syndromes. Moreover, different functional somatic syndromes seem to share common features, and they also share differences to other psychiatric disorders. They have a unique course and outcome, and treatment responsiveness is different from other DSM categories. This offers the basis for a clear definition of boundaries, and a clear description of a disorder is a necessary precondition for the validity of its classification criteria [1–3]. A further step in the validation of classification criteria is to show that the disorder of interests (e.g., somatic symptom disorder) has different predictors for persistence than other disorders such as anxiety and depression. McKenzie et al. (in this issue) are able to distinguish the predictors for these three groups, which is an additional confirmation of the necessity of a discrete diagnosis for disabling somatic symptoms [4]. The diagnostic criteria can be considered to be the frame of the picture of distressing somatic symptoms. The current discussion of the DSM-V proposal that has been published in a recent issue of this journal [5] shows a radical change to former approaches of classifying this syndrome. The prototype of somatoform disorders (“somatization disorder”) has been criticized as being overexclusive and employs poorly founded cutoff scores of number of somatic symptoms. The radical change of the new proposal is that number of symptoms plays only a minor role while the distress of symptoms associated with psychological features and symptom consequences are emphasized. Therefore, it can be expected that this new proposal identifies more of the patients who suffer from unclear somatic symptoms and who 0022-3999/09/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2009.11.001
present these symptoms in primary care and specialist offices. Defining such a somatic symptom disorder in DSM-V (or accordingly in Section F of ICD-10/11) requires not only the identification of somatic symptoms, but also specifying associated psychological features. This step was more than necessary to justify the classification as a DSM/ ICD Section F diagnosis. Therefore, the new proposal is a huge step forward. However, it also has to be discussed whether the presented proposal is the best that can be achieved or whether it is still possible to improve it. This discussion starts with several letters to the editor in this issue. Schröder and Fink state that it is problematic to include health care characteristics as classification criteria (e.g., health care utilization, physicians' miscontent, lacking reassurance of physicians' report) [6]. A century ago, people with tuberculosis have been considered to be treatment-resistant and costly, and they were sent for months or years to Swiss sanatoriums. However, this was not the fault of the patient, but the lacking knowledge of the experts. Why are patients with somatoform disorder described as being unresponsive to therapies [5]? Is it the patients' fault that medicine cannot offer effective interventions for them? Antidepressant treatment has been shown to work less effectively in terms of somatic symptoms than in terms of depressive affect [7–9]. Cognitive behavioral therapy, the best evaluated psychological intervention, shows moderate effectiveness in somatization syndrome compared to panic disorder or mild to moderate depressive disorders [10,11]. The classification approach has to be very careful in not blaming the patients for the helplessness of the experts. Considering the fact that many patients are seriously suffering from the symptoms, it is not surprising that they seek medical help until they feel relieved from their pains. Therefore, the major need is improved medical care and more powerful interventions. The article of Rosenzweig et al. [12] (in this issue) is highly relevant because it points to potentially new interventions. From a scientific point of view, it would be even more helpful to develop new therapies that integrate current findings for this patient group more rigorously. Many new concepts such as emotion regulation deficit, but also the results on the role of stress and others could be better integrated in current treatment approaches.
2
Editorials / Journal of Psychosomatic Research 68 (2010) 1–3
One basic assumption of many experts is that patients with somatic syndromes have a limited and inflexible organic causality model. Again, this seems to be more and more a result of what is problematic for the doctor but less of what is in the head of the patient. As Hiller et al. [13] confirmed (in this issue), patients with multiple somatic symptoms are fully able to consider psychological causes for their complaints, such as stress, conflicts and others. This has already been shown in former studies [14] and is confirmed with the semi-structured interview of Hiller et al. that might be more acceptable for some patients. In fact, the problematic patient is not only the one expressing primarily organic illness attributions but also the additional consideration of psychological causes is usually associated with comorbid depression. This points to the fact that treatment approaches should not try to reattribute patient's organic causal explanations to psychological causal explanations but should support the patient to make adequate use of the different illness attributions that are already in his or her mind. This is a great example how research of mechanisms and associated features could influence treatment planning. Further points of the new proposal for somatic symptom disorder have to be discussed in the upcoming months. The elimination of health anxiety/hypochondriasis is a serious point (again, see letter of Schröder and Fink in this issue). Health anxiety plays an important role in many medical conditions and can be a disorder of its own. It certainly has to be distinguished from somatic symptom disorder because anxiety is the major mechanism, the course of health anxiety is more fluctuating than the course of chronic somatic symptom disorder, and other mechanisms seem to be different. For patients with chronic organic conditions and increased health anxiety, it would be helpful to have a comorbid diagnosis that reflects patients' fears and subsequent problems even in the absence of other criteria of somatic symptom disorder. Current classification approaches have to be modified because they are overexclusive, but health anxiety seems still to be a discrete problem. Moreover, the current proposal for DSM-V does not address the issue of chronic pain conditions. Unfortunately, experts of psychosomatic medicine and experts of pain research are only rarely interacting. However, pain symptoms are the most frequent somatic symptoms, and there is a huge field of research and clinical practice that is specialized on pain. Many pain experts would prefer to have a specific pain diagnosis under DSM/ICD Section F to describe those patients with verified or supposed organic conditions that do not fully explain the severity or persistence of pain. It is unclear whether all of these patients should receive the diagnosis of chronic somatic symptom disorder or whether it is helpful to have a unique diagnosis for pain disorder under this category. Finally, the problem of finding an adequate name for this diagnosis is still unsolved. The current term somatoform is criticized because some health care professionals associate it with a psychological origin of symptoms. However, evidence is low that introducing a completely new term
avoids misinterpretation of its content. In fact, introducing a new term is a step backward because initiatives have to be restarted to introduce it, to increase its popularity, to describe it to other specialists, and to encourage them to use it. However, this is the basis for adequate care. Only a clear long-term perspective of being advantageous justifies these short-term disadvantages of introducing a new label. Therefore, it is not surprising that Creed et al. [15] (in this issue) report expert agreement that it might be easier to revitalize one of the already existing terms instead of introducing a completely new term. Moreover, the new label “somatic symptom disorder” does not seem to be unequivocally accepted; in contrast, several points of critique are already formulated especially from non-US countries (see Creed et al., in this issue). The confusion of the term symptom with disorder in a diagnosis might be a problem for people who prefer conceptual clarity. Moreover, what about “anxiety symptom disorder” or “bulimia symptom disorder”? This construction of terms might soon be associated with “reporting symptoms of type A, although in reality the patient suffers from disorder B.” Then, we are back to the problems we have with the current term somatoform. The discussion about an adequate name for the disorder can go on … This issue of the Journal of Psychosomatic Research shows that the knowledge on somatic symptoms is progressing, and more and more of the picture is drawn. The interaction of somatic experiences and psychological features (see, e.g., the papers of Delaroca-Chiapas et al. or Carney et al. in this issue) is crucial for the understanding of symptom development and symptom maintenance [16,17]. The investigation of symptom course starting from a single, acute symptom experience and ending with chronic conditions with comorbid depression and social withdrawal further increases the understanding of this condition (see Deary et al. in this paper [18]. More powerful treatments are necessary, and we should also think about prevention programs. Much could be achieved during the last years, but there is still much to do.
Winfried Rief Department of Psychology University of Marburg Marburg, Germany San Diego, USA E-mail address: [email protected] References [1] Guze SB. The validity and significance of the clinical diagnosis of hysteria (Briquet's syndrome). Am J Psychiatry 1975;132:138–41. [2] Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003;160:4–12. [3] Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatr 1970;126: 107–11.
Editorials / Journal of Psychosomatic Research 68 (2010) 1–3 [4] McKenzie M, Clarke DM, McKenzie DP, Smith GC. Which factors predict the persistence of DSM-IV depression anxiety, and somatoform disorder in the medically ill three months post hospital discharge? J Psychosom Res 2010;68:21–8. [5] Dimsdale J, Creed F. The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV—a preliminary report. J Psychosom Res 2009;66:473–6. [6] Schroeder A, Fink P. The proposed diagnosis of somatic symptom disorders in DSM-V: two steps forward and one step back? J Psychosom Res 2010;68:95–6. [7] Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Psychosom Med 1998;60:503–9. [8] Papakostas GI, Petersen T, Denninger J, Sonawalla SB, Mahal Y, Alpert JE, et al. Somatic symptoms in treatment-resistant depression. Psychiatry Res 2003;118:39–45. [9] Papakostas GI, Petersen T, Hughes ME, Nierenberg AA, Alpert JE, Fava M. Anxiety and somatic symptoms as predictors of treatmentrelated adverse events in major depressive disorder. Psychiatry Res 2004;126:287–90. [10] Allen LA, Escobar JI, Lehrer PM, Gara MA, Woolfolk RL. Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature. Psychosom Med 2002;64:939–50. [11] Looper KJ, Kirmayer LJ. Behavioral medicine approaches to somatoform disorders. J Consult Clin Psychol 2002;70:810–27.
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[12] Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D. Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. J Psychosom Res 2010;68:29–36. [13] Hiller W, Cebulla M, Korn H-J, Leibbrand R, Röers B, Nilges P. Causal symptom attributions in somatoform disorder and chronic pain. J Psychosom Res 2010;68:9–19. [14] Rief W, Nanke A, Emmerich J, Bender A, Zech T. Causal illness attributions in somatoform disorders—associations with comorbidity and illness behavior. J Psychosom Res 2004;57:367–71. [15] Creed F, Fink P, Guthrie E, Henningsen P, Rief W, Sharpe M, et al. Is there a better term than “Medically unexplained symptoms”? J Psychosom Res 2010;68:5–8. [16] De la Roca-Chiapas JM, Solís-Ortiz S, Fajardo-Araujo M, Sosa M, Córdova-Fraga T, Rosa-Zarate A. Stress profile, coping style, anxiety, depression and gastric emptying as predictors of the functional dyspepsia: a case-control study. J Psychosom Res 2010; 68:73–81. [17] Carney CE, Edinger JD, Morin CM, Manber R, Rybarczyk B, Stepanski EJ, et al. Examining maladaptive beliefs about sleep across insomnia patient groups. J Psychosom Res 2010;68:57–65. [18] Deary I, Wilson J, Carding P, MacKenzie K, Watson R. From dysphonia to dysphoria: Mokken scaling shows a strong, reliable hierarchy of voice symptoms in the Voice Symptom Scale questionnaire. J Psychosom Res 2010;68:67–71.