Design and validation of a diagnostic suspicion checklist to differentiate epileptic from psychogenic nonepileptic seizures (PNES-DSC).

OBJECTIVE: Psychogenic non-epileptic seizures (PNES) are complex clinical manifestations and misdiagnosis as status epilepticus remains high, entailing deleterious consequences for patients. Video-electroencephalography (vEEG) remains the gold-standard method for diagnosing PNES. However, time and economic constraints limit access to vEEG, and clinicians lack fast and reliable screening tools to assist in the differential diagnosis with epileptic seizures (ES). This study aimed to design and validate the PNES-DSC, a clinically based PNES diagnostic suspicion checklist with adequate sensitivity (Se) and specificity (Sp) to discriminate PNES from ES. METHODS: A cross-sectional study with 125 patients (n = 104 drug-resistant epilepsy; n = 21 PNES) admitted for a vEEG protocolised study of seizures. A preliminary PNES-DSC (16-item) was designed and used by expert raters blinded to the definitive diagnosis to evaluate the seizure video recordings for each patient. Cohen's kappa coefficient, leave-one-out cross-validation (LOOCV) and balance accuracy (BAC) comprised the main validation analysis. RESULTS: The final PNES-DSC is a 6-item checklist that requires only two to be present to confirm the suspicion of PNES. The LOOCV showed 71.4% BAC (Se = 45.2%; Sp = 97.6%) when the expert rater watched one seizure video recording and 83.4% BAC (Se = 69.6%; Sp = 97.2%) when the expert rater watched two seizure video recordings. CONCLUSION: The PNES-DSC is a straightforward checklist with adequate psychometric properties. With an integrative approach and appropriate patient history, the PNES-DSC can assist clinicians in expediting the final diagnosis of PNES when vEEG is limited. The PNES-DSC can also be used in the absence of patients, allowing clinicians to assess seizure recordings from smartphones.

An important contributing factor in dry eye disease: somatization.

PURPOSE: Somatization is an important mental process that may causes medically unexplained and treatment-resistant somatic symptoms. The aim of the study is assess the presence of somatization in patients with dry eye disease (DED). METHODS: Eighty-eight patients with no objective DED finding and ongoing DED treatment were included in this prospective and observational study. Patients with subjective symptoms formed the symptom group and patients without subjective symptoms formed the control group. All patients were scored with the Turkish version of the Ocular Surface Disease Index (OSDI), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Symptom Checklist-90-R (SCL-90R) somatization subscale, Toronto Alexithymia Scale (TAS), Pain Catastrophizing Scale (PCS), and Symptom Interpretation Questionnaire (SIQ). RESULTS: Mean OSDI score was significantly higher in the symptom group than in the control group. The mean HAM-D and HAM-A outcomes did not differ between the groups. The mean SCL-90R somatization subscale, TAS, and PCS scores were significantly higher in the symptom group than in the control group. In the SIQ, somatic attributional style score was significantly higher in the symptom group than in the control group. The SCL-90R somatization subscale, PCS, and somatic attributional style scores had positive and mild-moderate correlation with OSDI scores in the symptom group. The TAS score had positive and moderate correlation with OSDI scores in all sample analyses. CONCLUSION: Somatization should be considered in patients with DED with chronic ocular surface symptoms. Presence of subjective symptoms resistant to treatment may be an indicator of somatization.

A case of NMDAR Encephalitis with muscular pain as the main presentation.

BACKGROUND: Persistent somatoform pain disorder (PSPD) is often the initial diagnosis in patients seeking treatment in psychiatric departments, making it challenging to consider organic nervous system diseases. However, autoimmune encephalitis can present with atypical initial symptoms, leading to misdiagnosis or missed diagnosis. Lumbar puncture, with antibody support, plays a crucial role in diagnosing autoimmune encephalitis. CASE PRESENTATION: This report describes a 40-year-old male adult patient who was initially diagnosed with persistent somatoform pain disorder in 2022. The patient reported a reduction in pain while resting on his back. There were no fever or relevant medical history. Despite 8 months of symptomatic treatment, the symptoms did not improve. Moreover, the patient developed confusion, gibberish speech, non-cooperation during questioning, and increased frequency and amplitude of upper limb convulsions. Lumbar puncture revealed elevated protein levels and protein-cell dissociation. The autoimmune encephalitis antibody NMDAR (+) was detected, leading to a diagnosis of autoimmune encephalitis (NMDAR). CONCLUSION: Autoimmune encephalitis (NMDAR), starting with persistent somatoform pain (PSPD), often presents with atypical symptoms and can be easily misdiagnosed. Therefore, it is important to consider the possibility of organic nervous system disease in time, and to test serum or cerebrospinal fluid antibodies to rule out organic nervous system disease after symptomatic treatment of mental disorders is ineffective. This approach facilitates the early diagnosis of autoimmune encephalitis and other underlying organic neurological disorders.

The distribution of somatic symptom disorder and bodily distress syndrome in general hospital outpatients in China: A multicenter cross-sectional study.

OBJECTIVE: To investigate the distribution of somatic symptom disorder (SSD) and bodily distress syndrome (BDS) and analyze the differences in psychosocial characteristics of patients with the two diagnoses. METHODS: A total of 694 general hospital outpatients completed the diagnostic interviews for SSD and BDS, and a set of questionnaires evaluating their psychosocial characteristics. A secondary analysis of these data is done. RESULTS: SSD and BDS had a moderate overlap (kappa value = 0.43). Patients who fulfilled both SSD and BDS diagnosis showed significantly higher levels of symptom-related psychological distress (SSD-12), somatic symptom severity (PHQ-15), depression (PHQ-9), and general anxiety (GAD-7), as well as lower mental and physical quality of life (SF-12) compared to patients with neither diagnosis and patients with only one diagnosis. Patients with either diagnosis were associated with significantly higher psychosocial impairments as compared to those with neither diagnosis. Patients who only met SSD had higher SSD-12 scores, whereas those with only BDS had higher PHQ-15 scores (p<0.001). CONCLUSIONS: SSD and BDS appear to represent somewhat different psychopathologies, with SSD more associated with psychological distress and BDS associated with greater experience of somatic symptoms. Patients fulfilling both diagnosis show higher symptom severity in various psychosocial aspects.

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.

Phenomenon of Nightclub Shots: Mass Psychogenic Disease?

BACKGROUND: This article examines the possibility that the "nightclub shots" epidemic is a "mass psychogenic disease" phenomenon, by comparing the various cases of "mass sociogenic diseases" reported in the literature. We carried out a literature review on PubMed. The keywords used were "mass hysteria", "mass sociogenic disease", "mass psychogenic disease" and "epidemic of multiple unexplained symptoms". RESULTS: Our review of the literature revealed several elements common to the various "mass hysterias" we identified. These phenomena generally appear in a climate of anxiety specific to the era in which they occur, in this case the fear of bioterrorism in the 21st century. Symptoms are generally benign and transient, appearing and resolving easily without the identification of an organic cause. They usually occur in a small group of individuals, and more frequently in young people and women. The media can exacerbate the phenomenon. CONCLUSION: The phenomenon of epidemics of nightclub shots seems to fit into the common framework of "mass psychogenic diseases" identified in the literature. This diagnosis could therefore be evoked, in the absence of any other objective somatic explanation.

Infrared Thermography: Clinical Value for Diagnosing Persistent Somatoform Pain Disorders?

BACKGROUND: Patients with persistent somatoform pain disorder (PSPD) are not uncommon. Still, the disease diagnosis relies primarily on structured interviews, with no objective indicators yet available to aid in the diagnosis. This has led to low diagnostic rates and overconsumption of health care resources for the disorder. Although there is a large body of research to improve the diagnosis of the condition, there are currently no objective indicators available for diagnosis. OBJECTIVES: The aim of this study is to investigate the clinical value of infrared thermography (IRT) for diagnosing PSPD. STUDY DESIGN: This is a retrospective study. SETTING: A single academic hospital, outpatient setting. METHODS: The clinical data of patients diagnosed with PSPD in the Pain Department of the First Affiliated Hospital of the Army Medical University from September 2020 to September 2022 were analyzed. The differences in IR thermograms between PSPD patients and healthy controls were analyzed, as well as the relationship between the Hamilton Depression Rating Scale, Hamilton Anxiety Scale, Pittsburgh Sleep Quality Index (PSQI) score, Patient Health Questionnaire-15, and Symptom Check List-90 and the differences in IR thermograms of PSPD patients. RESULTS: The mean squared error, structural similarity measure, different hash, contrast, entropy, inverse variance, and correlation values of the IR thermogram helped to determine PSPD with statistically significant differences (P < 0.05). Inverse variance values were weakly negatively correlated with PSQI scores of PSPD patients (r -0.4721, P < 0.05). LIMITATIONS: This study was limited by its sample size and retrospective observational design. CONCLUSIONS: IRT analysis is a useful objective method in diagnosis of PSPD, which also provides a new line of thought for studying the pathogenesis of PSPD. KEY WORDS: Persistent somatoform pain disorder, PSPD, thermal imaging, infrared thermography, IRT, image texture characteristics, psychometric variables, image analysis.

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.

Diagnostic accuracy of the Dutch version of the Somatic Symptom Disorder - B Criteria Scale (SSD-12) compared to the Whiteley Index (WI) and PHQ-15 in a clinical population.

OBJECTIVE: Somatic Symptom and Related Disorders(SSRD) are characterised by an intense focus on somatic symptoms that causes significant distress. A self-report scale developed to assess distress as symptom-related thoughts, feelings, and behaviors (SSD-12) has proved to be a reliable, valid and time-efficient measure for Somatic Symptom Disorder(SSD). This cross-sectional study aimed to compare the SSD-12 with psychiatric assessment as gold standard in a Dutch clinical population for SSRD compared to other widely used measures. METHODS: Data were collected from adult patients visiting a specialised mental health outpatient clinic for SSRD in the Netherlands, between 2015 and 2017. Analyses included item evaluation, scale reliability, construct validity, diagnostic utility and cut points. Performance of SSD-12, Whiteley Index(WI) and PHQ-15 were compared in Receiver operating characteristics (ROC) curves. RESULTS: 223 patients with SSD, Functional Neurological Disorder, Illness Anxiety(IA) and no SSRD participated. SSD-12 items were normally distributed; total scores correlated with measures of health anxiety, anxiety and depression. The optimal cut point for the SSD-12 was 22 (sensitivity 75.9%, specificity 63.6%). The ROC area under the curve for SSD-12 was 0.75 compared to 0.68 for the WI and 0.65 for the PHQ-15. Combinations of those questionnaires did not yield better results than for the SSD-12 alone. CONCLUSION: The SSD-12 alone outperformed the WI and PHQ-15 and combined scales in effectively distinguishing SSRDs from other mental disorders. This may suggest that distress is a more accurate indicator of SSRD than earlier diagnostic criteria as operationalised in the WI and PHQ-15.

Same same, but different: effects of likelihood framing on concerns about a medical disease in patients with somatoform disorders, major depression, and healthy people.

BACKGROUND: Research has shown that patients with somatoform disorders (SFD) have difficulty using medical reassurance (i.e. normal results from diagnostic testing) to revise concerns about being seriously ill. In this brief report, we investigated whether deficits in adequately interpreting the likelihood of a medical disease may contribute to this difficulty, and whether patients' concerns are altered by different likelihood framings. METHODS: Patients with SFD (N = 60), patients with major depression (N = 32), and healthy volunteers (N = 37) were presented with varying likelihoods for the presence of a serious medical disease and were asked how concerned they are about it. The likelihood itself was varied, as was the format in which it was presented (i.e. negative framing focusing on the presence of a disease v. positive framing emphasizing its absence; use of natural frequencies v. percentages). RESULTS: Patients with SFD reported significantly more concern than depressed patients and healthy people in response to low likelihoods (i.e. 1: 100 000 to 1:10), while the groups were similarly concerned for likelihoods ⩾1:5. Across samples, the same mathematical likelihood caused significantly different levels of concern depending on how it was framed, with the lowest degree of concern for a positive framing approach and higher concern for natural frequencies (e.g. 1:100) than for percentages (e.g. 1%). CONCLUSIONS: The results suggest a specific deficit of patients with SFD in interpreting low likelihoods for the presence of a medical disease. Positive framing approaches and the use of percentages rather than natural frequencies can lower the degree of concern.

Psychosocial determinants of healthcare use costs in kidney transplant recipients.

Introduction: Psychosocial factors frequently occur in kidney transplant recipients (KTRs), leading to behavioral alterations and reduced therapeutic adherence. However, the burden of psychosocial disorders on costs for KTRs is unknown. The aim of the study is to identify predictors of healthcare costs due to hospital admissions and emergency department access in KTRs. Methods: This is a longitudinal observational study conducted on KTRs aged >18 years, excluding patients with an insufficient level of autonomy and cognitive disorder. KTRs underwent psychosocial assessment via two interviews, namely the Mini-International Neuropsychiatric Interview 6.0 (MINI 6.0) and the Diagnostic Criteria for Psychosomatic Research Interview (DCPR) and via the Edmonton Symptom Assessment System Revised (ESAS-R) scale, a self-administrated questionnaire. Sociodemographic data and healthcare costs for hospital admissions and emergency department access were collected in the 2016-2021 period. Psychosocial determinants were as follows: (1) ESAS-R psychological and physical score; (2) symptomatic clusters determined by DCPR (illness behavior cluster, somatization cluster, and personological cluster); and (3) ICD diagnosis of adjustment disorder, anxiety disorder, and mood disorder. A multivariate regression model was used to test the association between psychosocial determinants and total healthcare costs. Results: A total of 134 KTRs were enrolled, of whom 90 (67%) were men with a mean age of 56 years. A preliminary analysis of healthcare costs highlighted that higher healthcare costs are correlated with worse outcomes and death (p < 0.001). Somatization clusters (p = 0.020) and mood disorder (p < 0.001) were positively associated with costs due to total healthcare costs. Conclusions: This study showed somatization and mood disorders could predict costs for hospital admissions and emergency department access and be possible risk factors for poor outcomes, including death, in KTRs.

Prediction of the prognosis of somatoform disorders using the Minnesota Multiphasic Personality Inventory.

BACKGROUND: Somatoform disorders are frequently resistant to treatment. This study aimed to determine the utility of the Minnesota Multifaceted Personality Inventory (MMPI) in predicting the prognosis of somatoform disorders. METHODS: Overall, 125 patients diagnosed with somatoform disorders between January 1, 2013 and December 31, 2017 in the psychiatric department of Fukushima Medical University Hospital were included. Patients with positive outcomes were identified based on a subjective estimation regarding (1) pain and (2) social functions, including activities of daily living. They were divided into the improved group (IG) and the non-improved group (NIG). Each factor was then descriptively compared between the two groups, and the sensitivity and specificity were determined. RESULTS: The NIG had significantly higher scores but only on the Hy scale. Thus, the optimal Hy scale cutoff score was calculated. The cutoff point was 73.5, with a sensitivity of 55.7% and a specificity of 71.7%. CONCLUSION: An MMPI Hy scale score higher than a cutoff value of 73.5 predicts a poor response to conventional supportive psychotherapy or drug therapy in patients with somatoform disorders. This cutoff point may be used as an important index for selecting treatment for somatoform disorders.

Case-controlled field study of the ICD-11 clinical descriptions and diagnostic requirements for Bodily Distress Disorders.

AIMS: Mental disorders characterized by preoccupation with distressing bodily symptoms and associated functional impairment have been a target of major reconceptualization in the ICD-11, in which a single category of Bodily Distress Disorder (BDD) with different levels of severity replaces most of the Somatoform Disorders in ICD-10. This study compared the accuracy of clinicians' diagnosis of disorders of somatic symptoms using either the ICD-11 or ICD-10 diagnostic guidelines in an online study. METHODS: Clinically active members of the World Health Organization's Global Clinical Practice Network (N = 1065) participating in English, Spanish, or Japanese were randomly assigned to apply ICD-11 or ICD-10 diagnostic guidelines to one of nine pairs of standardized case vignettes. The accuracy of the clinicians' diagnoses as well as their ratings of the guidelines' clinical utility were assessed. RESULTS: Overall, clinicians were more accurate using ICD-11 compared to ICD-10 for every presentation of a vignette characterized primarily by bodily symptoms associated with distress and impairment. Clinicians who made a diagnosis of BDD using ICD-11 were generally correct in applying the severity specifiers for the condition. LIMITATIONS: This sample may represent some self-selection bias and thus may not generalize to all clinicians. Additionally, diagnostic decisions with live patients may lead to different results. CONCLUSIONS: The ICD-11 diagnostic guidelines for BDD represent an improvement over those for Somatoform Disorders in ICD-10 in regard to clinicians' diagnostic accuracy and perceived clinical utility.

Persistent physical symptoms after COVID-19 infection and the risk of Somatic Symptom Disorder.

OBJECTIVE: Evidence shows that many patients with COVID-19 present persistent symptoms after the acute infection. Some patients may be at a high risk of developing Somatic Symptom Disorder (SSD), in which persistent symptoms are accompanied by excessive and disproportionate health-related thoughts, feelings and behaviors regarding these symptoms. This study assessed the frequency of persistent physical symptoms and SSD and their associated factors in patients with confirmed COVID-19. METHODS: We conducted a longitudinal retrospective study after the first two French lockdowns at the Lille University Hospital (France), including all patients with confirmed COVID-19. Persistent physical symptoms and excessive preoccupations for these symptoms were measured 8 to 10 months after the onset of COVID-19. The combination of the Patient Health Questionnaire-15 and the Somatic Symptom Disorder-B Criteria Scale was used to identify the individuals likely to present with SSD. Two linear regression models were performed to identify sociodemographic and medical risk factors of SSD. RESULTS: Among the 377 patients with a laboratory-confirmed diagnosis, 220 (58.4%) completed the questionnaires. Sixty-five percent of the 220 included patients required hospitalization, 53.6% presented at least one persistent physical symptom and 10.4% were considered to present SSD. Female sex, older age, infection during the second wave and having probable PTSD were significantly associated with the severity of SSD and SSD was associated with a significantly higher healthcare use. CONCLUSIONS: The identification of SSD should encourage clinicians to move beyond the artificial somatic/psychiatric dualism and contribute to a better alliance based on multi-disciplinary care.

Validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder and illness anxiety disorder in pathological health anxiety: Should we close the chapter?

OBJECTIVE: To investigate the validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder (SSD) and illness anxiety disorder (IAD) in pathological health anxiety: the excessive and recurrent fear of, or preoccupation with, having or developing a serious health condition. METHODS: We compared SSD to IAD in pathological health anxiety (N = 334) with regard to concurrent, antecedent, and predictive validators. This was primarily a cross-sectional study, though we studied the effect of CBT longitudinally. Because we were interested in the discriminatory value of SSD and IAD over and above trait health anxiety, we used trait health anxiety as a covariate. RESULTS: SSD (68%; 228/334) vs. IAD (32%; 106/334) differences were mostly non-significant and small in sociodemographics, core clinical characteristics, apparent course, etiological attribution, and physician visits (gs = -0.18-0.20; RRs = 0.84-1.09; IRRs = 0.87-0.99). However, SSD was associated with a significantly higher somatic symptom burden (gs = 0.20-0.72), more psychologist visits (IRR = 2.02, 95% CI: 1.24-3.28), and slightly higher disability (g = 0.22, 95% CI: 0.03-0.42). There was no significant difference in symptom reduction during CBT (g = -0.16, 95% CI: -0.37-0.05). CONCLUSION: Although not all differences between SSD and IAD in pathological health anxiety seem to be explained by the level of trait health anxiety, the SSD vs. IAD distinction appears to convey little useful information in pathological health anxiety. Tentatively, considering the well-documented clinical characteristics and effective clinical interventions, it is probably most helpful to regard pathological health anxiety as a de facto anxiety or perhaps obsessive-compulsive spectrum disorder, regardless of the DSM-5 diagnosis of SSD or IAD.

Loneliness in patients with somatic symptom disorder.

OBJECTIVES: Patients with somatoform disorders often experience loneliness. They feel misunderstood and socially rejected. Whereas loneliness is related to several medical conditions, social support can minimize loneliness. In the current study, differences in loneliness and the evaluation of social support between patients with Somatic Symptom Disorder (SSD) and healthy controls were investigated using standardized questionnaires. In addition, the relation between loneliness and somatic symptoms was investigated. METHODS: In a cross-sectional study design, a group of patients with SSD (n=75) was compared to a healthy control group (n=112). It was hypothesized that [1] patients with SSD experience more loneliness and evaluate their social support more negatively than healthy controls and [2] loneliness will correlate positively with experienced somatic symptoms. RESULTS: In comparison to healthy controls, patients with SSD experienced more loneliness and their evaluation of social support was more negative. In addition, loneliness correlated positively with the degree of experienced somatic symptoms. CONCLUSIONS: Patients with SSD experienced lower social support, more loneliness, and across the two groups loneliness was positively associated with somatic symptoms. Effect sizes were all large. Therefore, these results may have implications for the treatment of SSD.

How the integration of normal medical test results can be improved in patients with somatoform disorders-An experimental study.

BACKGROUND: We examined whether the difficulties of patients with somatoform disorders (SFDs) in integrating medical reassurance can be altered by preventing patients from devaluing reassuring information through defensive cognitive strategies. METHOD: Patients with SFD (n = 60), patients with major depression (n = 32), and healthy volunteers (n = 37) watched a videotaped doctor's report, which provided medical reassurance for gastroenterological complaints. Subsequently, participants were asked about their perception of the report. In the SFD sample, patients' appraisal of the reassuring was experimentally modulated: In one condition, doubts about the validity of the doctor's diagnostic assessment were triggered; in another condition, the devaluation of medical reassurance was blocked through underscoring the validity of the doctor's diagnostic assessment; and a control condition received no manipulation. RESULTS: As evident on all outcome variables, patients with SFD had more difficulty integrating medical reassurance than depressed and healthy people. Within the SFD sample, participants from the experimental condition blocking the devaluation of medical reassurance rated the likelihood of an undetected serious disease to be significantly lower than the other two conditions. They also reported less emotional concern and a lower desire to seek the opinion of another doctor. CONCLUSIONS: By comparing patients with SFD to both a healthy and a clinical control group, the current study suggests that the difficulty in processing reassuring medical information is a specific psychopathological feature of SFD. Furthermore, our results suggest that the integration of medical reassurance can be improved by preventing patients from devaluing reassuring information through dismissive cognitive strategies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.