[DSM-5: from 'somatoform disorders' to 'somatic symptom and related disorders']. / DSM-5: van somatoforme stoornissen naar 'somatic symptom and related disorders'

BACKGROUND: The DSM-IV somatoform disorder category was controversial and has undergone major changes in DSM-5. AIM: To provide a critical description of DSM-5 somatic symptoms and related disorders (SSD). METHOD: To review the new classification system for somatic symptom and related disorders (SSD) as set out in DSM-5 RESULTS: Whereas the symptoms of somatoform disorder were always considered to be medically unexplained, in DSM-5 the symptoms of somatic symptom disorder can now sometimes be explained by a medical condition. The criterion is that the individual has a maladaptive reaction to a somatic symptom. In DSM-5 the terms somatisation disorder, pain disorder and undifferentiated somatoform disorder have been discarded, whereas factitious disorder as well as psychological factors affecting other medical conditions have been added to somatic symptom disorder and other disorders. Conversion disorder remains as it was in DSM-IV. Hypochondriasis has been renamed 'illness anxiety disorder'. CONCLUSION: The new description of somatic symptom disorder in DSM-5 represents a big step forwards, because the decision has been made to use, for classification, a positive criterion, namely maladaptive reaction to a somatic symptom, instead of the earlier negative criterion, namely that the symptoms should be medically unexplained. Before attaching the ssd label to an illness, the clinician will have to weigh up the clinical consequences of this psychiatric diagnosis.

Self-critical perfectionism and its relationship to fatigue and pain in the daily flow of life in patients with chronic fatigue syndrome.

BACKGROUND: Research suggests that the personality factor of self-critical or maladaptive perfectionism may be implicated in chronic fatigue syndrome (CFS). However, it is not clear whether self-critical perfectionism (SCP) also predicts daily symptoms in CFS. Method In the present study we investigated whether SCP predicted fatigue and pain over a 14-day period in a sample of 90 CFS patients using a diary method approach. After completing the Depressive Experiences Questionnaire (DEQ) as a measure of SCP, patients were asked each day for 14 days to complete Visual Analogue Scales (VAS) of fatigue, pain and severity of depression. Data were analysed using multilevel analysis. RESULTS: The results from unconditional models revealed considerable fluctuations in fatigue over the 14 days, suggesting strong temporal variability in fatigue. By contrast, pain was relatively stable over time but showed significant inter-individual differences. Congruent with expectations, fixed-effect models showed that SCP was prospectively associated with higher daily fatigue and pain levels over the 14-day period, even after controlling for levels of depression. CONCLUSIONS: This is the first study to show that SCP predicts both fatigue and pain symptoms in CFS in the daily course of life. Hence, therapeutic interventions aimed at targeting SCP should be considered in the treatment of CFS patients with such features.

[Chronic fatigue syndrome: a psychoneuroimmunological perspective]. / Chronischevermoeidheidssyndroom: een psychoneuro-immunologisch perspectief.

This article casts light on the contribution that psychoneuroimmunology can make in the search for the cause of chronic fatigue syndrome (cfs). Several studies suggest that psychosocial and physical stress may play an important predisposing, precipitating and perpetuating role in cfs. Moving on from these studies we now discuss recent research into the stress-related pathophysiological mechanisms of the illness. Although there is evidence for a hypofunctional stress response, a hyperactive immune response and disturbances in the interaction between both, the findings are not consistent. Longitudinal studies are needed to unravel the pathophysiology of cfs still further. In such studies the concept of 'sickness response' and 'sickness behaviour' may perform an important heuristic function.

[Stress research in psychiatry: a complex story]. / Stressonderzoek in de psychiatrie: een complex verhaal.

Research into the role of stress in psychiatric disorders faces major challenges. However, over the last few decades there has been considerable progress in this area as a result of methodological, technological and conceptual developments. The advent of recursive and non-linear models and research into the neurobiology of stress have made important contributions to this progress. Not only have these developments increased our insight into the aetiopathogenesis and classification of psychiatric disorders, they also have important implications for clinical assessment and treatment. In particular, renewed interest in the role of meaning-making has opened up a number of new avenues for clinical practice and research.

[Fifty years of psychiatry at the interface between psyche and soma: a SWOT analysis]. / Vijftig jaar psychiatrie op de grens tussen psyche en soma: een SWOT-analyse.

During the past 50 years the border area between psychiatry and somatic medicine has undergone remarkable changes. Theories have become better-founded, both psychologically and neurobiologically, research has become more sophisticated, and liaison-psychiatrists and health psychiatrist/behavioural medicine psychologists have played an increasingly active role in this domain. At the beginning of the 21st century modern psychosomatic medicine is facing new challenges; these include how to create a workable diagnostic classification system, how to instruct and educate both health professionals and lay-persons to an adequate level, how to utilize innovative research paradigms without having recourse to reductionism and how to implement in medical practice treatments that are geared to the needs of the individual patient.

Depression, attribution style and self-esteem in chronic fatigue syndrome and fibromyalgia patients: is there a link?

The aims of the present study were to compare a single diagnosis (chronic fatigue syndrome, CFS) and a double diagnosis (CFS + fibromyalgia, CFS+FM) group regarding depression, attribution style and self-esteem as well as to examine whether attribution style is a mediator in the relationship between self-esteem and depression. Eighty-five patients (CFS: 47, CFS+FM: 38) completed questionnaires on attribution style, self-esteem and depression. The single and double diagnosis groups tended to differ slightly, but the differences were never statistically significant. In addition, only one condition was met of the four conditions mentioned by Baron and Kenny to establish that mediation exists between two variables. In conclusion, an external attribution style does not protect the CFS or CFS+FM patients with a low self-esteem from depression. The prevalence rate of depression was high in both patient samples, of which clinicians should be aware.

Stress, depression and fibromyalgia.

There is increasing evidence that stress and depression may play a crucial role in the aetiology and pathophysiology of fibromyalgia (FM). We first review recent studies on the possible role of life stress, including childhood trauma, in FM. Subsequently we focus on clinical and aetio-pathogenetic links between stress, depression and pain. We put forward the hypothesis that chronic stress/depression may contribute to a dysregulation of neuro-endocrine, immune and central pain mechanisms in FM. Finally, we discuss some future directions, including the use of new conceptual models, research topics and strategies, as well as potential implications from recent studies in affective disorders for the treatment of FM.

Evaluation of a brief chronic pain management program: effects and limitations.

The short- and long-term efficacy of a multidisciplinary pain management program was evaluated in a group of 35 chronic pain patients. At posttreatment, patients reported lower pain levels, more up-time, less medication consumption, an increase in positive cognitions about pain, and more (psychologically oriented) active coping. At follow-up, treatment gains were only partly maintained. A theoretical model regarding the impact of the treatment program was discussed. Plans for future efforts to enhance transfer and maintenance of therapeutic benefits were presented.

Etiopathogenesis of reflex sympathetic dystrophy: a review and biopsychosocial hypothesis.

Reflex sympathetic dystrophy (RSD) is an enigmatic condition. Many clinicians, however, believe that psychological factors could contribute to the onset and persistence of the syndrome. In this article we critically review the evidence from psychometric and psychodynamic/biographical studies that suggests a role for such factors. An etiopathogenetic hypothesis based on the authors' clinical experience and the foregoing literature also encompasses elements of stress-coping theory, cognitive-behavioral views on chronic pain, and the psychobiological approach to sympathetic nervous system dysfunction. Implications of this model for future psychological research and the therapeutic treatment of RSD are discussed.

Burning mouth syndrome. Successful treatment with combined psychotherapy and psychopharmacotherapy.

A case is presented that illustrates the possible role of significant life events and depression in the etiology of the burning mouth syndrome. Furthermore, successful treatment with a combination of a selective serotonin re-uptake blocking antidepressant (sertraline) and psychodynamically oriented psychotherapy is described.

Is there a relationship between reflex sympathetic dystrophy and helplessness? Case reports and a hypothesis.

Five case reports that illustrate the possible contribution of psychological factors in the etiopathogenesis of reflex sympathetic dystrophy (RSD) are presented. All five patients at the time of physical trauma were confronted with a significant loss that either accidentally coincided with the trauma, or was related to the experience of the trauma itself. The patients' reaction to the loss was invariably characterized by helplessness. A biopsychosocial hypothesis which considers the possible role of psychophysiological and behavioral aspects of helplessness in the precipitation, maintenance, and/or enhancement of RSD is outlined.

Premorbid "overactive" lifestyle in chronic fatigue syndrome and fibromyalgia. An etiological factor or proof of good citizenship?

OBJECTIVE: In a former study, we have shown that patients suffering from chronic fatigue syndrome (CFS) or chronic pain, when questioned about their premorbid lifestyle, reported a high level of "action-proneness" as compared to control groups. The aim of the present study was to control for the patients' possible idealisation of their previous attitude towards action. METHODS: A validated Dutch self-report questionnaire measuring "action-proneness" (the HAB) was completed by 62 randomly selected tertiary care CFS and fibromyalgia (FM) patients, as well as by their significant others (SOs). RESULTS: HAB scores of the patients and those of the SOs were very similar and significantly higher than the norm values. Whether or not the SO showed sympathy for the patient's illness did not influence the results to a great extent. SOs with a negative attitude towards the illness even characterized the patients as more "action-prone." CONCLUSIONS: These results provide further support for the hypothesis that a high level of "action-proneness" may play a predisposing, initiating and/or perpetuating role in CFS and FM.

Does high 'action-proneness' make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study.

Degree of premorbid 'action-proneness' was measured, using a self-administered questionnaire, in 35 patients suffering from chronic fatigue syndrome (CFS), all the members of 'ME'-self help groups and all those meeting CDC-criteria of CFS. The results were compared with those of 30 chronic idiopathic musculoskeletal pain patients, 34 patients with a chronic organic condition, and 34 neurotic patients without primary somatic complaints. Statistical analysis showed that CFS patients described themselves as significantly more 'action-prone' than the last two groups, and to a degree which was comparable with the chronic pain group. The results could not be explained by concomitant depression and are in accordance with anecdotal reports of premorbid hyperactive lifestyle in CFS patients. Further investigations seem worthwhile to test the hypothesis that hyperactivity might be a predisposing factor for chronic illness behaviour in CFS patients.

Attention to chronic pain is dependent upon pain-related fear.

Pain interrupts, distracts, and is difficult to disengage from. In this study, the role of pain-related fear in moderating attentional interference produced by chronic pain was investigated. Forty chronic pain patients completed a list of questionnaires assessing pain severity, pain-related fear (Tampa Scale for Kinesiophobia), and negative affect (Negative Emotionality scale). Attentional interference was measured by a numerical interference test. Multiple regression analysis revealed that the attentional interference was best predicted by the interaction between pain severity and pain-related fear. These results are discussed in terms of how pain-related fear creates a hypervigilance to pain.

Neuro-algodystrophy: a psychiatrist's view.

In this article the syndrome of neuro-algodystrophy is discussed from a psychiatric point of view. First, a review is given of the scarce psychological literature on this subject. Secondly, a retrospective study of 32 neuro-algodystrophy patients, seen in a psychiatric consultation practice, is presented; in nearly all cases of this highly selected group, an obvious time-relation with a significant psychological factor could be determined, and in more than 60%, some kind of affective loss was concerned. Thirdly, some theoretical speculations about these findings are formulated. Finally, it is concluded that the diagnostic and therapeutic contribution of the psychiatrist may be valuable, at least in some cases of neuro-algodystrophy.

Tender points or tender patients? The value of the psychiatric in-depth interview for assessing and understanding psychopathological aspects of fibromyalgia.

Although the aetiology of fibromyalgia is still unexplained, evidence favouring the role of psychopathology is accumulating, at least in a subgroup of patients; however, the exact aetiological significance of psychopathology in this syndrome is difficult to assess. Various assessment strategies have both strengths and weaknesses. Two case reports are presented which illustrate the value of the psychiatric in-depth interview (including psychodynamic-biographical history taking) for assessing and understanding psychological/psychiatric aspects of fibromyalgia.

The effects of catastrophic thinking about pain on attentional interference by pain: no mediation of negative affectivity in healthy volunteers and in patients with low back pain.

BACKGROUND: Previous studies have shown that catastrophic thinking about pain enhances attentional interference in healthy volunteers. OBJECTIVE: To investigate whether the attentional effects of pain catastrophizing can be accounted for by the more general predisposition of negative affectivity. METHODS: Sixty-seven pain-free students participated in the first experiment, and 33 patients with chronic low back pain participated in the second experiment. In both experiments, participants performed an auditory reaction time task while being exposed to a series of threatening electrocutaneous stimuli. Retardation in reaction times to auditory probes during pain was taken as an index of the attentional interruption by pain. Participants also completed self-report instruments of negative affectivity and pain catastrophizing. RESULTS: In both experiments, pain catastrophizing enhanced attentional interference by pain. This effect was most pronounced immediately after the onset of the electrocutaneous stimulus. The effect remained after controlling for the effects of negative affectivity. CONCLUSIONS: Catastrophic thinking about pain enhances attentional interruption by pain in normal samples, as well as in clinical samples of patients with chronic back pain. This effect is specific to pain catastrophizing and cannot be explained by the more general disposition of negative affectivity.

An open study of sertraline in acute and continuation treatment of depressed out-patients.

The efficacy and tolerability of sertraline in 422 out-patients with major depression (DSM-III-R) was evaluated in an open multicentre 8-month study. Patients received sertraline 50 mg/day; if there was insufficient response at week 4, the dose was increased to 100 mg/day. After 8 weeks, 68.6% of patients had responded (> or = 50% reduction in Montgomery Asberg depression rating scale and clinical global impression scale scores of two or less (improvement of illness) and three or less (severity of illness); of patients receiving continuation treatment, 87.9% maintained at least a partial response at the final visit. The clinical response to the 50 mg/day dose was maintained throughout the acute treatment in 64% of patients. In all, 23% of the patients had mild or moderate drug-related gastrointestinal disturbances, which generally disappeared after 2 weeks. Only 8% of the patients withdrew because of side-effects. Just over half of the patients were taking other psychotropic drugs. Nevertheless the results of this open study are consistent with those of controlled studies in which sertraline was effective and well tolerated, in acute and continuation treatment for major depression, at 50 mg/day in most patients.