Somatoform Disorders in Primary Care-An Exploratory Mixed-Methods Study on Experiences, Challenges and Coping Strategies of General Practitioners in the Federal Republic of Germany.

Somatoform symptoms are widely spread in outpatient care. For treating physicians, it can be challenging to establish a relationship that is conducive to compliance and to take stabilising action when dealing with affected patients. As primary care providers, GPs are usually the first point of contact for patients with somatoform disorders; they set the course for stabilisation and further care. To date, there is a lack of studies that focus on how GPs respond to such patients. In particular, strategies for establishing a stable doctor-patient relationship have hardly been explored. Consequently, this study investigated how GPs recognise the symptoms of somatoform disorders, what significance they attach to them and how they handle patients. The primary focus is on experienced patient properties, assumed causes of somatoform disorders, obstacles and complexities in consultation, care and stabilisation strategies, as well as diagnostic forms of support. A total of 2797 GPs in the German federal states of Hesse, Rhineland-Palatinate and Baden-Württemberg were surveyed anonymously by means of a written questionnaire between January and August 2023. A t-test was performed with independent samples to determine significant differences between two groups. In addition, 64 GPs were interviewed between March and April by means of qualitative semi-standardised interviews. The respondents make use of a wide range of communication and stabilisation strategies when treating somatoform physical complaints. The GPs combine the establishment of a tangential doctor-patient relationship with measures to consistently exclude physical causes and to enable the best possible assessment of patients, as well as to gently introduce them to the clinical picture of somatoform disorders. Most physicians are not familiar with current clinical guidelines. Cooperation with specialists and therapists is widely described as complicated. GPs have access to a wide range of communication and stabilisation strategies for the management of somatoform physical complaints. Yet, they experience interaction with this patient group as difficult in daily practice. GPs articulate a clear need for more external support. Apart from increasing therapeutic care capacities and interdisciplinary structures, it seems advisable to extend low-threshold therapy and support services.

In many mental health and some somatic disorders, efficacy of therapist-guided remote CBT and in-person CBT does not differ.

SOURCE CITATION: Zandieh S, Abdollahzadeh SM, Sadeghirad B, et al. Therapist-guided remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized controlled trials. CMAJ. 2024;196:E327-E340. 38499303.

Integrated care model for patients with functional somatic symptom disorder - a co-produced stakeholder exploration with recommendations for best practice.

BACKGROUND: Functional somatic symptoms (FFS) and bodily distress disorders are highly prevalent across all medical settings. Services for these patients are dispersed across the health care system with minimal conceptual and operational integration, and patients do not currently access therapeutic offers in significant numbers due to a mismatch between their and professionals' understanding of the nature of the symptoms. New service models are urgently needed to address patients' needs and to align with advances in aetiological evidence and diagnostic classification systems to overcome the body-mind dichotomy. METHOD: A panel of clinical experts from different clinical services involved in providing aspects of health care for patients with functional symptoms reviewed the current care provision. This review and the results from a focus group exploration of patients with lived experience of functional symptoms were explored by the multidisciplinary expert group, and the conclusions are summarised as recommendations for best practice. RESULTS: The mapping exercise and multidisciplinary expert consultation revealed five themes for service improvement and pathway development: time/access, communication, barrier-free care, choice and governance. Service users identified four meta-themes for best practice recommendations: focus on healthcare professional communication and listening skills as well as professional attributes and knowledge base to help patients being both believed and understood in order to accept their condition; systemic and care pathway issues such as stronger emphasis on primary care as the first point of contact for patients, resources to reduce the length of the patient journey from initial assessment to diagnosis and treatment. CONCLUSION: We propose a novel, integrated care pathway for patients with 'functional somatic disorder', which delivers care according to and working with patients' explanatory beliefs. The therapeutic model should operate based upon an understanding of the embodied nature of patient's complaints and provide flexible access points to the care pathway.

Persistent physical symptoms: definition, genesis, and management.

Persistent physical symptoms (synonymous with persistent somatic symptoms) is an umbrella term for distressing somatic complaints that last several months or more, regardless of their cause. These symptoms are associated with substantial disability and represent a major burden for patients, health-care professionals, and society. Persistent physical symptoms can follow infections, injuries, medical diseases, stressful life events, or arise de novo. As symptoms persist, their link to clearly identifiable pathophysiology often weakens, making diagnosis and treatment challenging. Multiple biological and psychosocial risk factors and mechanisms contribute to the persistence of somatic symptoms, including persistent inflammation; epigenetic profiles; immune, metabolic and microbiome dysregulation; early adverse life experiences; depression; illness-related anxiety; dysfunctional symptom expectations; symptom focusing; symptom learning; and avoidance behaviours, with many factors being common across symptoms and diagnoses. Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation. If basic care is insufficient, targeted psychological and pharmacological interventions can be beneficial. A better understanding of the multifactorial persistence of somatic symptoms should lead to more specific, personalised, and mechanism-based treatment, and a reduction in the stigma patients commonly face.

An integrated mental health video consultations model for patients with somatic symptom disorder in primary care: The randomized VISION pilot trial.

OBJECTIVE: Symptoms of somatic symptom disorder (SSD) are one of the most common reasons for consultations in primary care. However, specialized psychological services are mostly unavailable. This pilot trial aimed to determine the feasibility, acceptability, and safety of the integrated mental health video consultations VISION model for patients with SSD in primary care. METHODS: We conducted a parallel group, randomized controlled pilot trial involving fifty-one patients with SSD from ten primary care practices in Germany, who we randomized to the VISION model or enhanced treatment-as-usual (eTAU). The VISION model comprised five video consultations which featured diagnostic clarification, psychoeducation (acknowledging and legitimizing of symptoms), and brief psychological therapy. eTAU included training primary care practice teams on the DSM-5 concept of SSD and on current guideline recommendations for its treatment in primary care. We assessed feasibility as the primary outcome at 6-months, measuring efficiency of recruitment, intervention acceptability, and safety. RESULTS: Recruitment was efficient reflected in an overall recruitment yield (number randomized per number screened) of 55% (51/92) and a consent rate (number randomized per number eligible) of 94% (51/54). Acceptability of the intervention was high with 98% (123/125) of the video consultations conducted as planned. No serious adverse events were reported in either group. CONCLUSION: An integrated mental health video consultations VISION model for patients with SSD presenting to primary care is feasible, acceptable, and safe. Potential clinical effectiveness of the model should be evaluated in confirmatory trial implementing the multifaceted approach tailored to the individual patient with SSD directly into primary care practice. TRIAL REGISTRATION: The trial protocol was registered at German Clinical Trials Register (number: DRKS00026075, https://www.drks.de).

Strategies to improve implementation of collaborative care for functional disorders and persistent somatic symptoms: A qualitative study using a Research World Café design.

INTRODUCTION: Persistent somatic symptoms and functional disorders (PSS/FD) are often complex conditions requiring care from multiple disciplines. One way of bringing the different disciplines together is through collaborative care. Little is known about the implementation barriers faced and relevant strategies to tackle the barriers in this field. Therefore, using expert knowledge, we aim to develop realistic strategies for dealing with implementation barriers of collaborative care in PSS/FD. METHODS: The Research World Café method is a single-session, expert-based method with multiple focus-groups forming and reforming to answer a set of inter-related questions, under the guidance of moderators. Using this method, participants involved in PSS/FD care across different areas of healthcare in the Netherlands developed several realistic strategies for dealing with ten implementation barriers for collaborative care in PSS/FD that were previously identified in a Delphi study. Strategies were grouped into strategy clusters using a card-sorting task. RESULTS: Thirty-three participants took part, representing ten different disciplines, most commonly physiotherapists, psychologists, and physicians. In total, 54 strategies, identified in response to the ten barriers, were grouped into eight strategy clusters. The strategy clusters were professional education, communication, care coordination, care pathways, joint consults, funding, patient involvement, and prevention. CONCLUSION: We identified a number of useful strategies for dealing with implementation barriers for collaborative care in PSS/FD. Many strategies provided ways to deal with multiple barriers at once. The effects of applying these strategies in collaborative care in PSS/FD will need testing through implementation studies, as well as in other areas needing multidisciplinary care.

[Experiential acceptance in the treatment of complex somatic symptom disorder]. / Ervaringsgerichte acceptatie bij de behandeling van complexe somatisch-symptoomstoornis.

BACKGROUND: Acceptance and Commitment Therapy (ACT) plays an important role in the treatment of patients with refractory Somatic Symptom Disorder and related disorders with complex problems and/or somatic or psychiatric comorbidity (complex SSD). AIM: To gain insight into the possible role of (experiential) acceptance in improved quality of life during and after treatment. METHOD: Observational longitudinal study in 41 patients with complex SSD treated at Altrecht Psychosomatic Medicine Eikenboom. They completed online questionnaires around the start and completion of treatment and after six months of follow-up. Assessed were experiential acceptance (AAQ-II-NL) and three aspects of quality of life (RAND-36: mental health, physical functioning, general health perception). The associations between changes in acceptance and quality of life were determined. RESULTS: Acceptance increased significantly from treatment initiation to follow-up. Mental health increased significantly between start and end of treatment, and general health perception increased significantly in the follow-up period. Physical functioning did not change. During treatment, an increase in acceptance was significantly associated with improvement in mental health and general health perception; during follow-up, an increase in acceptance was associated with an improvement in mental health. CONCLUSION: The current study demonstrates that an increase in experiential acceptance goes hand in hand with an improvement in mental health and general health perception. These results indicate the potential importance of acceptance-based treatment in patients with complex SSD. Experimental research with more frequent measurements is needed to test a temporal relationship between (first) increased acceptance and (then) improved quality of life.

Exercise as Treatment for "Stress-Related" Mental Disorders.

The beneficial impact of physical activity on preventing and treating mental disorders has captured growing (research) interest. This article aims to provide a concise overview of essential evidence regarding the effectiveness and underlying mechanisms of physical activity for individuals with mental disorders clustered as "stress-related" conditions. Empirical findings (e.g., longitudinalprospective studies, interventional randomized-controlled-trials, reviews, meta-analyses) regarding the effects of physical activity in the prevention and treatment of stress-related mental disorders are summarized. Furthermore, potential mechanisms underlying these effects are discussed, and recommendations regarding the use of physical activity are outlined. The majority of studies indicate good efficacy of physical activity in prospectively lowering the risk for the incidence of subsequent stress-related mental disorders as well as in the treatment of manifest disorders. Most evidence targets unipolar depressive disorder and, secondly, anxiety disorders. Research regarding posttraumatic stress disorder, obsessive-compulsive disorders, and somatoform disorders is promising but scarce. Physical activity seems to be useful as a stand-alone-treatment as well as in combination with other psychotherapeutic or pharmacological treatments. Multiple intertwined physiological, psychological, and social mechanisms are assumed to mediate the beneficial effects. Recommendations regarding physical activity can orientate on official guidelines but should consider the individual needs and circumstances of each subject. In summary, physical activity seems to be effective in the prevention and treatment of stressrelated mental disorders and, therefore, should be fostered in healthcare-settings. Future studies are needed to clarify partly inconsistent patterns of results and to close research gaps, e.g., concerning somatoform disorders.

A Clinical Trial of Psychodynamic-Interactional and Body Therapy in Somatoform Pain Disorders - Positive Interpersonal Experiences for Patients with Early Trauma.

Objectives: The aim of this clinical trial was to explore whether psychodynamic-interactional therapy leads to a better outcome in the treatment of somatoform pain disorders when combined with body therapy. Methods: 30 patients diagnosed with this disorder took part in outpatient group therapies with 25 sessions. In the intervention condition, sessions based on psychodynamic-interactional and body therapy took place in weekly change, while in the control condition all sessions were based on psychodynamic-interactional therapy. Data were collected with self-report measures at the beginning and end of therapy and at the 6-months follow-up. Results: Under both conditions somatic and psychological symptoms merely remained stable from the first to the third measurement time. However, patients expressed a high level of satisfaction with the relationships in the group. Conclusions: Contrary to the assumptions, the two therapy conditions did not differ in the treatment outcome. Both conditions proved successful in providing patients with supporting interpersonal experiences.

Clinical impact and misdiagnosis of functional ophthalmological symptoms: a case report.

BACKGROUND: There is a high prevalence of somatoform disorders and medically unexplained symptoms. When it comes to deciding whether a patient is able to work, it is essential to differentiate a somatoform disorder from a factitious disorder. The case presented demonstrates the impact on disability benefits and the subsequent psychosocial repercussions of misdiagnosing between a factitious disorder and a somatoform disorder. CASE PRESENTATION: A 42-year-old Caucasian woman worked as a 100% fiduciary accountant until the age of 32 when she was placed on medical leave due to persistent trigeminal neuralgia. Afterward, she developed total blindness, not explained by a physiological process, accompanied by distress in a crucial emotional context. We evaluated the patient for a revision of a disability income after a diagnosis of factitious disorder with severe consequences such as disability income suspension and family conflict. Our psychiatric examination concluded the diagnoses of pain disorders related to psychological factors and a dissociative neurological symptom disorder with visual disturbance. CONCLUSIONS: Blindness not explained by a physiological process may accompany trauma and psychological distress. Differentiating this pathology from factitious disorder or simulation is essential from an insurance medicine point of view, but also for its treatment.

The Amplification of Symptoms in the Medically Ill.

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

Women-only versus mixed-gender groups in multimodal, day clinic treatment of trauma-related disorders.

Background: In the German healthcare system benefits include inpatient and day clinic psychotherapy of trauma-related disorders, which are often provided in gender specific groups. Despite this widespread practice, the actual impact and potential outcome have been studied relatively scarcely and are still open to debate. The present study therefore examines whether the therapeutic relationships in the group vary depending on the group composition and whether this has an effect on therapy outcome. Methods: 66 patients (N = 55 women) were treated in our multimodal, day clinic groupbased treatment program and filled out symptom questionnaires (ETI, BDI-II, PHQ-15, Questionnaire on social support) at admission and discharge and the Group Questionnaire (GQ; including subscales positive bonding, positive working and negative relationships) at the end of each of the eight weeks of treatment. Patients took part in five women-only and six mixed-gender groups and underwent therapy in a closed group format, so that they began and ended therapy within the same group. All patients were diagnosed with trauma-related disorders, which included PTSD, cPTSD, depression, somatoform disorders and further mental diseases. Outcome data were examined using functional regression analysis and linear mixed models. Results: In women-only groups, positive bonding and positive working relationship were significantly higher than in mixed-gender groups. Negative relationship ratings were significantly lower in women-only groups, especially in the middle phase of treatment. However, no effect of an exclusively female group composition on treatment outcome was found, except for the higher increase of perceived social support for patients treated in women-only groups. Conclusions: Group relationships were considered more pleasant in women-only groups than in mixed-gender groups, but this had no effect on the symptom-based therapy outcome. To enhance feelings of safety and comfort, traumatized women should have the possibility to choose whether to be treated in a women-only or a mixed-gender group.

The biopsychosocial model in paediatric clinical practice-An interdisciplinary approach to somatic symptom disorders.

AIM: The paper aims to show how the biopsychosocial (BPS) model can be applied as a clinical method and guide the assessment and treatment of children and adolescents with somatic symptom disorders (SSD). METHODS: Based on relevant literature and our clinical work with children and adolescents with SSD, we have developed a method to ensure a structured, interdisciplinary examination of biological, psychological and social factors, operationalising the BPS model into a clinical method. RESULTS: The BPS model renders assessment and treatment of complex conditions as a basis for evaluating phenomena not confined by diagnostic tools, but still includes all information from these tools. It requires an interdisciplinary approach, giving individual patient and caregivers a central position. A thorough medical examination is required as a starting point for assessments. Good results rest upon a shared understanding between patient, caregivers and professionals. CONCLUSIONS: 'Biopsychosocial' is often claimed as a basis for clinical work with complex cases, medical, functional and psychiatric, but scarcely with a corresponding BPS method or practice. The BPS method should guide further development of holistic, interdisciplinary health care on all levels, to assess and help children and adolescents with SSD.

Psychogenic (nociplastic) pain: Current state of diagnosis, treatment options, and potentials of neurosurgical management.

Classification of pain syndromes is quite multifaceted. However, pathogenetic classification by which chronic pain syndromes are usually divided into nociceptive, neuropathic and psychogenic, is crucial in choosing treatment tactics. In modern classifications, psychogenic pain is distinguished from nociceptive pain (associated with direct tissue injury or damage) and neuropathic pain (in which lesion can only be determined morphologically). Mental disorders play a leading role in psychogenic pain. Here, somatic/neurological disorders, if any, are of no pathogenetic significance in the dynamics of pain syndrome. There are certain algorithms (though not yet fully developed) and even guidelines for diagnosing and treating nociceptive and neuropathic pain, whereas psychogenic pain has been and still is almost out of sight for a long time. Despite its considerable prevalence, attitude towards it is still uncertain. Until now, it has no single classification, nor any strategy with regards to diagnosis, treatment and prevention.

Using clinical patient characteristics to predict treatment outcome of cognitive behavior therapies for individuals with medically unexplained symptoms: A systematic review and meta-analysis.

OBJECTIVE: For individuals with medically unexplained symptoms (MUS), cognitive behavioral therapy (CBT) is the best-evaluated treatment. This systematic review and meta-analyses identify clinical patient characteristics associated with the treatment outcome of CBT for MUS. METHODS: A systematic literature search (PubMed, PsycInfo, Web of Science) resulted in 53 eligible studies; of these 32 studies could be included in meta-analyses. Pooled correlation coefficients between predictors and treatment outcome were calculated with a random-effects model. Moderator analyses were conducted to examine differences between subgroups of MUS and different levels of methodological study quality. RESULTS: Meta-analyses demonstrated that individuals with higher symptom intensity (r = 0.38; p < 0.001), lower physical functioning (r = -0.29; p < 0.001), lower emotional and social functioning (r = -0.37; p < 0.001), more potential symptom-related incentives (r = -0.15; p = 0.001), or longer symptom duration (r = 0.10; p = 0.033) at the beginning of treatment reported less change of symptom severity until the end of therapy or higher end-of-treatment symptom severity. The pooled effect sizes did not differ between certain subgroups of MUS or between different levels of methodological quality. CONCLUSION: Our findings indicated that clinical characteristics of MUS patients are associated with treatment outcome of CBT. We discuss how the results can be used to optimize and personalize future treatments for MUS.

Neuromodulation for the treatment of functional neurological disorder and somatic symptom disorder: a systematic review.

Functional neurological disorder and somatic symptom disorder are complex neuropsychiatric conditions that have been linked to circuit-based dysfunction of brain networks. Neuromodulation is a novel therapeutic strategy capable of modulating relevant brain networks, making it a promising potential candidate for the treatment of these patient populations. We conducted a systematic review of Medline, Embase and PsycINFO up to 4 March 2021. Trials investigating neuromodulation devices for the treatment of functional neurological disorder or somatic symptom disorder were selected. Extracted variables included study design, demographic and clinical characteristics, psychiatric comorbidity, neurostimulation protocols, clinical outcome measures and results. 404 studies were identified with 12 meeting inclusion criteria. 221 patients were treated in the included studies with mean study sample size of 18 (4-70). Five studies were randomised clinical trials. Functional motor symptoms (six weakness, four movement disorders) were the most studied subpopulations. Transcranial magnetic stimulation (TMS) was the most frequently used device (10 studies), followed by electroconvulsive therapy (one study) and direct-current stimulation (one study). Treatment protocols varied in intended therapeutic mechanism(s): eight studies aimed to modulate underlying network dysfunction, five aimed to demonstrate movement (one also leveraged the former) and three boosted their primary mechanism with enhanced suggestion/expectation. All but one study reported positive results; however, methodological/outcome heterogeneity, mixed study quality and small sample sizes precluded quantitative meta-analysis. Neuromodulation, particularly TMS for the treatment of functional motor symptoms, shows preliminary promise in a growing line of research. Larger, sham-controlled studies are needed to further establish efficacy and better understand therapeutic mechanisms.

Psychological well-being in patients undergoing stem cell transplantation

The aim of the study is to determine the psychological well-being of patients who underwent stem cell transplantation. This cross-sectional study was conducted with 100 patients. Data were collected face-to-face using an introductory information form and the Brief Symptom Inventory.When the results of the patients were examined, the interpersonal sensitivity of the sub-dimensions of the scale was found to be 5.0 ± 4.06, depression 7.60 ± 5.37, and anxiety disorder 7.90 ± 5.34. There was a significant difference between the diagnosistime of the patients and all sub-factors of the scale, except phobic anxiety. It was found that the psychological state of the patients was directly related to the time of first diagnosis. As a result, the importance of following the psychological processof the patients during the treatment process was revealed when planning nursing care.

Significant Improvement of Somatic Symptom Disorder With Brief Psychoeducational Intervention by PMHNP in Primary Care.

OBJECTIVE: Patients with somatic symptom disorders (SSD) are prevalent in primary care, urgent care, and emergency rooms and present with reduced quality of life, increased disability, and suicidality . Criteria for SSD include (1) somatic symptoms that cause distress and disrupt life; (2) concurrent physical illness with thoughts and feelings that are disproportionate to the seriousness of the illness; and (3) distress which is persistent and causes suffering. The frequency of SSD in the general population is 5% to 7%; however, in primary care, it is 5% to 35% . Because patients present with anxiety, depression, and/or pain, providers are flummoxed when diagnostic findings do not match symptom intensity. The purpose of this project was to provide an intervention for patients with SSD and measure its effectiveness on their somatic symptoms. METHOD: This study provided a single-session, 30-minute psychoeducational intervention for patients to explain brain pathways for pain and the body's response to stress, including scientific benefits of exercise and healthy diet. Patients were asked questions using the motivational interviewing technique OARS (open-ended question, affirmation, reflection, summary) and were encouraged to talk about their concerns. The study used a pre- and post-intervention visual analogue scale and a self-reported Patient Health Questionnaire-15 both before and 3 weeks post-intervention. RESULTS: Measurements showed significant symptom improvement immediately after the intervention with sustained improvement 3 weeks post-intervention. CONCLUSIONS: This intervention demonstrates an effective treatment for this insidious illness, which plagues up to 35% of patients in primary care.

The 'medically unexplained symptoms' syndrome concept and the cognitive-behavioural treatment model.

The American Psychiatric Association's, 2013 DSM-5 abandoned the use of the term 'medically unexplained symptoms' for non-neurological disorders. In the UK, treatments for various medical illnesses with unexplained aetiology, such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia, continue to fall under an MUS umbrella with cognitive behavioural therapy promoted as a primary therapeutic approach. In this editorial, we comment on whether the MUS concept is a viable diagnostic term, the credibility of the cognitive-behavioural MUS treatment model, the necessity of practitioner training and the validity of evidence of effectiveness in routine practice.