Longing for existential recognition: a qualitative study of everyday concerns for people with somatoform disorders.

OBJECTIVE: Patients with somatoform disorders could be vulnerable to stressors and have difficulties coping with stress. The aim was to explore what the patients experience as stressful and how they resolve stress in everyday life. METHODS: A cross-sectional retrospective design using 24 semi-structured individual life history interviews. Data-analysis was based on grounded theory. RESULTS: A major concern in patients was a longing for existential recognition. This influenced the patients' self-confidence, stress appraisals, symptom perceptions, and coping attitudes. Generally, patients had difficulties with self-confidence and self-recognition of bodily sensations, feelings, vulnerability, and needs, which negatively framed their attempts to obtain recognition in social interactions. Experiences of recognition appeared in three different modalities: 1) "existential misrecognition" covered the experience of being met with distrust and disrespect, 2) "uncertain existential recognition" covered experiences of unclear communication and a perception of not being totally recognized, and 3) "successful existential recognition" covered experiences of total respect and understanding. "Misrecognition" and "uncertain recognition" related to decreased self-confidence, avoidant coping behaviours, increased stress, and symptom appraisal; whereas "successful recognition" related to higher self-confidence, active coping behaviours, decreased stress, and symptom appraisal. CONCLUSION: Different modalities of existential recognition influenced self-identity and social identity affecting patients' daily stress and symptom appraisals, self-confidence, self-recognition, and coping attitudes. Clinically it seems crucial to improve the patients' ability to communicate concerns, feelings, and needs in social interactions. Better communicative skills and more active coping could reduce the harm the patients experienced by not being recognized and increase the healing potential of successful recognition.

Measurement and assessment of somatic symptoms.

Somatic symptoms are common presentations in health settings. They can manifest as symptoms of another underlying mental disorder or be termed as medically unexplained. When they are medically unexplained they are invariably subsumed under the diagnostic categories of somatoform disorders. They are associated with interference in functioning, poor quality of life and are burdensome on health resources. The measurement of these symptoms is essential for understanding the individual and planning treatment. There are various instruments that have somatic symptoms measurement in their items. The tools have included somatic symptoms measurement in measuring general psychopathology, somatic symptoms as part of anxiety and depression, somatic symptoms specifically, and as a screening instrument for somatoform disorders. The advantages and disadvantages of common measures have been discussed. It appears that no one measure fulfils the essential criteria of an ideal measure for somatic symptoms. The measures of somatic symptoms should also be culturally sensitive and serve diagnostic, prognostic and heuristic purposes. These aspects are highlighted in the review.

Somatization and somatic symptom presentation in cancer: a neglected area.

Abstract The recognition of somatization process in cancer patients is a challenging and neglected area, for the extreme difficulty in differentiating and assessing the psycho(patho)logical components from those biologically determined and related to cancer and cancer treatment, as well as for the scarce usefulness of rigid categorical DSM criteria. However, several dimensions of somatization (and the interconnected concept of abnormal illness behaviour) have been shown to be diagnosable in cancer patients and to negatively influence coping and quality of life outcomes. An integration of the formal DSM-ICD nosology with a system specifically taking into account the patients' emotional responses to cancer and cancer treatment, such as the Diagnostic Criteria for Psychosomatic Research (DCPR), is suggested. More data on some specific symptom dimensions, including pain, fatigue and sexual disorders, are needed to examine their possible psychological components. More research is also needed regarding the association of somatization with personality traits (e.g. type D distressed personality, alexithymia), developmental dimensions (e.g. attachment), and cultural issues (e.g. culturally mediated attributional styles to somatic symptoms). Also, the impact and effectiveness of specific therapeutic intervention in 'somatizing' cancer patients is necessary.

Somatic symptoms in primary care and psychological comorbidities in Qatar: neglected burden of disease.

Although somatic complains are the predominant reasons for seeking general medical care, there has been limited research on the clinical presentation of somatic symptoms in primary care settings in developing countries. The frequency of somatic symptoms in primary care in Qatar and its relationship to comorbidities of mental disorders is presented here. A total of 2,320 Arab patients were approached, of whom 76% agreed to participate for the survey conducted among primary healthcare (PHC) centre patients. The study was conducted with the help of general practitioners (GPs), using the General Health Questionnaire (GHQ-12), Patient Health Questionnaire (PHQ)-8 for depression, the Generalized Anxiety Disorder Scale (GAD)-7 for anxiety, PHQ-15 for somatic symptoms and the Psychological Stress Measure (PSM)-9 for stress. Of the subjects with somatic symptoms (229 cases), most were Qataris (57.2%). Poor hearing (52.1%), palpitation (47.1%) and stomach pain (43.8%) were the most common in men, whereas constipation (54.6%), feeling depressed (50.9%), and poor hearing (50.6%) were the most common in women; 48.5% had more than four somatic symptoms. Somatic symptoms were severe in 31.9%. Somatic symptoms were associated with depression (15.3%), anxiety (8.7%) and stress disorders (19.2%). The study findings revealed that somatic symptoms were significantly associated with socio-economic status. Somatic symptoms were significantly associated with depression, anxiety and stress disorders.

Occlusal dysesthesia: a qualitative systematic review of the epidemiology, aetiology and management.

Occlusal dysesthesia refers to a persistent complaint of uncomfortable bite sensation with no obvious occlusal discrepancy. This systematic review aimed to draw a picture of such patients, to present an agreement of previously reported diagnostic criteria and to analyse the evidence level of the recommended management approaches. An electronic search for all relevant reports on occlusal dysesthesia was thoroughly performed based on previous nomenclatures (e.g. phantom bite, occlusal hyperawareness) in PubMed and The Cochrane Library in July, 2011. A total of 84 reports were matched, among which only 11 studies were included after a two-step (abstract and detailed full-text revision) screening process. Additionally, a thorough manual review of reference lists of the included reports enabled the inclusion of two additional studies. Data analysis revealed that 37 occlusal dysesthesia patients presented a mean age of 51.7 ± 10.6 years and were predominantly women (male/female: 1/5.1) with symptom duration of more than 6 years (average: 6.3 ± 7.5 years) and with concomitant psychological disturbances (e.g. mood disorders, somatoform disorders, personality disorders). Only four authors presented diagnostic criteria for occlusal dysesthesia, which served as the basis for an agreement in the diagnostic criteria. Treatment approaches included psychotherapy, cognitive/behaviour therapy, splint therapy and prescription of anti-depressants or anti-anxiety drugs. Classification of evidence level of management approaches, however, revealed that most of them were expert opinions with single- or multiple-case report(s). Future studies are necessary for a deeper understanding of the mechanisms behind the occlusal dysesthesia symptoms, and consequently, for improvements in evidence-based management approaches.

Widespread pain symptoms and psychological distress in southern Chinese with orofacial pain.

The study investigated the experience of widespread pain (WP) symptoms and psychological distress in southern Chinese with orofacial pain (OFP). A community-based, cross-sectional case-control study involving people aged 35-70 registered with the Hospital Authority/University of Hong Kong Family Medicine Clinic served as the sampling frame. People with recent OFP symptoms and a group without OFP took part. Standard questions were asked about OFP conditions in the previous month. Psychological status was evaluated through depression, and non-specific physical symptoms (NPS) scores were measured with depression and somatization sub-scales of the Symptom Checklist-90. Widespread pain was determined using body outline drawings to identify painful sites prior to a standard clinical examination. Two hundred people with OFP and 200 without OFP participated. Compared with 5.0% in the comparison group (P = 0.005), 13.5% of participants with OFP had WP (OFP/WP). Multiple OFP symptoms were more common in the OFP/WP sub-group than the OFP sub-group without WP (OFP/No WP) (P < 0.002). Sixty-three percent of the OFP/WP sub-group had moderate/severe depression scores compared with 26.0% in the OFP/No WP sub-group (P < 0.001). When pain items were included and excluded, 92.6% and 88.9% of the OFP/WP sub-group had moderate/severe NPS scores, respectively compared with 68.5% and 65.0% in the OFP/No WP sub-group (P = 0.004). Co-morbid WP occurred relatively often in southern Chinese with OFP. Psychological distress was common in OFP sufferers, particularly those with WP. A multidisciplinary approach to treatment including cognitive/behavioural therapy should be considered in Chinese people with OFP as part of a WP pattern.

Influence of psychopathologies on craniomandibular disorders.

Psychopathologies play a role in the etiology and maintenance of craniomandibular disorders (CMD). In this study, the craniomandibular index was applied to valuate signs and symptoms of CMD in 60 dentate patients, who were assigned to 2 groups: symptomatic (n=35) and asymptomatic (n=25). An interview on psychopathologies was carried out with the aim to detect the presence of some mood disorders, such as depression, dysthymic and bipolar I disorders. Among these disturbances, depression was the most significant aspect to be reported (p<0.05) since it was present in most symptomatic patients. This important interaction was also significantly correlated (p<0.05) with the Palpation Index. These results suggest that psychopathological aspects could increase muscle tenderness and pain in addition to sleep dysfuntions and other physical complaints. Therefore, psychopathologies should be regarded as an important aspect in patients with orofacial pains.

Influence of psychopathologies on craniomandibular disorders

Psychopathologies play a role in the etiology and maintenance of craniomandibular disorders (CMD). In this study, the craniomandibular index was applied to valuate signs and symptoms of CMD in 60 dentate patients, who were assigned to 2 groups: symptomatic (n=35) and asymptomatic (n=25). An interview on psychopathologies was carried out with the aim to detect the presence of some mood disorders, such as depression, dysthymic and bipolar I disorders. Among these disturbances, depression was the most significant aspect to be reported (p<0.05) since it was present in most symptomatic patients. This important interaction was also significantly correlated (p<0.05) with the Palpation Index. These results suggest that psychopathological aspects could increase muscle tenderness and pain in addition to sleep dysfuntions and other physical complaints. Therefore, psychopathologies should be regarded as an important aspect in patients with orofacial pains.

Os transtornos psíquicos podem desempenhar um importante papel na etiologia e manutenção das desordens craniomandibulares (DCM). Desta forma, neste estudo, foi aplicado o índice craniomandibular (ICM), o qual permite detectar a presença de sinais e sintomas de DCM em 60 pacientes totalmente dentados. Estes pacientes foram divididos em dois grupos: sintomáticos (n=35) e assintomáticos (n=25). Um teste psiquiátrico foi administrado para diagnosticar patologias psíquicas pertencentes ao DSM-IV, como a depressão e os transtornos distímico e bipolar I. Das patologias psíquicas relacionadas aos transtornos de humor, a depressão mostrou uma relação estatisticamente significante (p<0,05) com os pacientes sintomáticos para DCM. Ao analisar o índice de palpação separadamente, essa relação se manteve significante (p<0,05) numa escala crescente de valores, demonstrando a ação destes transtornos sobre a sintomatologia dolorosa muscular. Assim sendo, os transtornos mentais exerceriam uma influência considerável na etiologia da DCM, na medida em que potencializariam a dor. Isso ocorreria em função do aumento da tensão muscular, dos distúrbios do sono e de outras alterações fisiológicas advindas destes transtornos.

Costly patients with unexplained medical symptoms: a high-risk population.

OBJECTIVES: To identify a group of costly patients with unexplained medical symptoms (UMS), and address their needs. METHODS: Prospective controlled trial; 42 patients with annual costs of care of $6500 or more were randomized into an intervention and a usual care group. A primary care team with expertise in the biopsychosocial (BPS) approach implemented the intervention. RESULTS: In the intervention group, the annual number of visits to consultants declined from 31.8 to 12.6 (p<.0001) and 14.6 (p=.72) after 1 and 2 years, respectively; visits to hospital emergency wards declined from 33.5 to 4.1 (p<.0001) and 3.5 (p=.18); and in-hospital days declined from 112.7 to 19 (p<.0001) and 6.5 (p=.25). Those parameters remained unchanged in the control group. Five years follow-up demonstrated a reduction in mortality rates between the two groups: 6/21 versus 17/21 (p<0.001). CONCLUSIONS: When compared to usual care, a BPS intervention was followed by a decline in patients' visits to medical settings and health-care expenditures, along with significant decline in mortality rate. PRACTICE IMPLICATION: Costly UMS patients should be identified every year and treated using a BPS approach.

Effects of fluvoxamine on anxiety, depression, and subjective handicaps of chronic dizziness patients with or without neuro-otologic diseases.

A prospective, open-label clinical trial was conducted for two aims: first, to evaluate the role of fluvoxamine, one of selective serotonin reuptake inhibitors, in the treatment of dizziness for the first time and to investigate its effective mechanisms. Second, to test the hypothesis that dizziness in patients without abnormal neuro-otologic findings would be induced by psychiatric disorders rather than by unnoticed neuro-otologic diseases. Nineteen patients with neuro-otologic diseases (Group I) and 22 patients in whom standard vestibular tests revealed no abnormal findings (Group II) were treated by fluvoxamine (200 mg/day) for eight weeks. Subjective handicaps due to dizziness using a questionnaire, anxiety and depressive symptoms measured with the Hospital Anxiety and Depression Scale (HADS), and stress hormones (vasopressin and cortisol) were examined before and 8 weeks after treatment. Overall, fluvoxamine decreased subjective handicaps of both Groups I and II. Fluvoxamine decreased HADS of only patients whose subjective handicaps were reduced (=responders) in both groups, suggesting that fluvoxamine was effective for dizziness via psychiatric action rather than a recovery of vestibular function through serotonergic activation. In non-responders of Group II, pre-treatment HADS was higher than in Group I non-responders and it was not decreased by the treatment, suggesting that dizziness of Group II non-responders was due to severe psychiatric disorders rather than unnoticed neuro-otologic diseases. Anxiety and depression components of HADS showed a good correlation at both pre- and post-treatment periods. No post-therapeutic decrease was observed in either vasopressin or cortisol even in responders, suggesting that dizziness was not the sole cause of stress in chronic dizziness patients. In conclusion, patients with or without physical neuro-otologic deficits who report chronic dizziness accompanied by anxiety and depression (as measured by HADS) showed improvements across a full range of subjective handicaps and psychological distress, while patients with physical neuro-otologic defects and minimal anxiety or depression did not benefit. The main causes of dizziness in patients without physical neuro-otologic findings were psychiatric disorders.

Case and care complexity in the medically ill.

The authors have argued that complexity in general health care is increasingly prevalent because of the increase in patients who have multimorbid conditions, and the increased professional and technical possibilities of medicine. In the increasingly complex care systems, it is necessary-specifically when treating patients in need of integrated care by several providers-that an optimal match between case and care complexity be found in order to prevent poor outcomes in this vulnerable group. The authors discussed several approaches to case complexity that can be identified in the literature. Most of them seem unsuitable for adjusting case and care complexity, and inadequate for designing multidisciplinary care. Theoretic approaches to case complexity may be of interest, but did not result in clinically meaningful information. The INTERMED, which can be considered the first empirically based instrument to link case and care complexity, is an attempt to improve care delivery and outcomes for the complex medically ill.

Prevalence, comorbidity and impact of irritable bowel syndrome in Norway.

OBJECTIVE: To study the prevalence of irritable bowel syndrome (IBS) and its comorbidity in a Norwegian adult population. MATERIAL AND METHODS: In 2001, 11,078 inhabitants (aged 30-75 years) in Oppland County were invited to take part in a public health survey. A total of 4622 subjects (42%) completed the questionnaires on symptoms of IBS (Rome II criteria), comorbidity, health-care visits and medications. The impact of comorbidity on global health, working disability and use of health-care resources in subjects with IBS was explored by stepwise logistic regression. RESULTS: The population prevalence of IBS was 388/4622 (8.4% (95% CI: 7.6-9.4%)) with a female predominance and an age-dependent decrease. The proportion who had consulted for IBS ranged from 51% among 30-year-olds to 79% in 75-year-olds (p=0.05). IBS was associated with musculoskeletal complaints (OR = 2.4-3.4 for six different items), fibromyalgia (OR = 3.6 [2.7-4.8]), mood disorder (OR = 3.3 (2.6-4.3)), reduced global health (OR = 2.6 (2.1-3.2)), working disability (OR = 1.6 (1.2-2.1)), more frequent health-care visits and use of medications (OR 1.7-2.3). When controlling for comorbidity, reduced global health (OR = 1.5 (1.1-2.0)) and use of alternative health care (OR = 1.7 (1.3-2.4)) remained associated with IBS. Severity of abdominal pain/discomfort was a predictor of having to seek a physician for IBS (OR = 1.3 (1.2-1.5)). CONCLUSIONS: Symptoms of IBS were reported by 8% of Norwegian adults and had resulted in consultations with physicians for the majority in the long run. Subjects with IBS in the community were characterized by frequent somatic and psychiatric comorbidity. Their observed reduced health, working disability and increased use of health resources were largely explained by comorbid symptoms and disorders.

The presentation of irritable bowel syndrome in the context of somatization disorder.

BACKGROUND AND AIMS: Somatization disorder, a female predominant disorder, has been found with higher than expected prevalence in previous studies of irritable bowel syndrome (IBS) and might be responsible for some of the comorbidity and excessive health care resource use associated with IBS. The study's aim was to determine within a female IBS population the degree of segregation of psychiatric illness, functional disorders, and health care utilization with somatization disorder. METHODS: In a prospective, 6-month follow-up study, psychiatric disorders were assessed with the Diagnostic Interview Schedule, gastrointestinal and other symptoms with self-report questionnaires, and medically unexplained complaints by thorough chart review. The setting was a university gastroenterology clinic. The participants were a convenience sample of female clinic attendees with IBS (N = 56). RESULTS: Somatization disorder was diagnosed in 25% of patients and highly probable in another 5%. Somatization disorder was associated with significantly greater numbers of gastrointestinal and other symptoms, psychiatric disorders, physicians consulted, telephone calls to physicians, urgent care visits, medication changes, and missed work days and with benzodiazepine use. On follow-up, somatization disorder was associated with psychiatric and IBS symptoms, medication changes, and treatment dissatisfaction. Both somatization disorder and other psychiatric illnesses were associated with other functional gastrointestinal disorders; only somatization disorder remained predictive in a regression model that controlled for the presence of other psychiatric illness. CONCLUSIONS: Among female IBS patients attending a university gastroenterology clinic, many aspects of comorbidity and health care behaviors previously associated with IBS segregated with the diagnosis of somatization disorder. Recognition and appreciation of somatization disorder in IBS have important ramifications for the conduct of research and clinical practice.

Public health and insomnia: economic impact.

There seems to be a lack of understanding between practitioners and patients on the topic of insomnia. One adult out of four complains of insomnia; however only one insomniac out of four has ever complained about it to their practitioner during a visit made for another problem and only one out of twenty has come to discuss specifically the problem of his or her insomnia. Only a few patients with insomnia take a treatment for it. This gap between the patient's feeling and the practitioner's answer has to be better understood if we want to know why insomnia seems to be so prevalent and what impact it has on society. One aspect may be a question of definition. Insomnia may be considered an ordinary complaint (after one poor night) or as a chronic disease. Practitioners have poor knowledge about sleep disorders and may be embarrassed about coping with an impairment they never specifically learned to manage. The second aspect concerns the impact of insomnia on daytime alertness and performance. While patients usually complain of an impaired daytime functioning with a feeling of fatigue, sleepiness, and risk of mistakes, many studies of insomniacs do not reveal any increased sleepiness or decrease of performance (measured by objective tests) the day following a poor night. Practitioners may therefore find it difficult to understand the real impact of insomnia on daytime functioning. The third aspect is related to the large co-morbidity between insomnia and psychiatric diseases, especially depression and anxiety. It does make it harder for practitioners to define whether the sleep impairment suffered by their patient is the cause for other symptoms or the consequence of an underlying disease. Thus, it makes it all the more difficult for the practitioner to determine which treatment is the most appropriate. These aspects have to be clarified if one wants to estimate the real impact of insomnia on society. It could be useful to both practitioners and patients to have a better understanding on the relationship between poor sleep and daily lives.

[Somatization of erectile disorders by the introduction of sildenafil]. / Somatisering van erectiestoornissen door de komst van sildenafil.

With the introduction of the erection-supporting oral drug sildenafil (Viagra) the development of somatic treatments of male sexual dysfunction has reached a temporary peak. The availability of a medicament that is easy to take will result in an increase of the incidence and possibly also the prevalence of erectile disorder. It may even lead to the myth that only a perfect erection is normal. The question is where to draw the line between a normal inconvenience of life and a serious disease. The erection pill will probably be preferred to all other treatments. Therefore, most patients will consult their family physician, who will refer only difficult cases to urologists or sexologists. Physicians should take 'the man behind the penis' into consideration before writing a prescription, otherwise a distressed man without an erection might become a distressed man with an erection. In the long run, psychosexual therapy is less expensive than taking sildenafil for many years.

Screening for somatizing patients in the pulmonary subspecialty clinic.

Somatizing patients present a history of vague, unexplained medical symptoms. This study compared somatizing patients with pulmonary control subjects by using the Diagnostic Interview Schedule (DIS-III-R), the Illness Attitude Scales (IAS), and the Minnesota Multiphasic Personality Inventory (MMPI-2). The groups differed in the number of somatization symptoms reported and in the frequency of somatization disorder diagnoses when the screening criteria were used. The somatizing group obtained higher scores on the bodily preoccupation and hypochondriacal beliefs subscales of the IAS; no differences were found on the MMPI-2. These findings indicate that the DSM-III-R somatization screening items can be useful for detecting somatization when patients present with unexplained respiratory complaints.