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.

Somatic symptoms associated with mental distress during the COVID-19 pandemic: a systematic review.

OBJECTIVE: The primary objective of this article was to systematically review the prevalence of somatic symptoms in patients, healthcare workers and general population during the COVID-19 pandemic. The secondary objectives were to record the association between somatic symptoms and indices of mental distress and to record the qualitative characteristics of such somatic complaints. METHODS: Following the PRISMA methodology we systematically searched PubMed, Scopus and Google Scholar for primary research reporting on somatic symptoms in association with mental distress. We specifically sought papers reporting on bodily distress disorder, somatic symptoms disorder or medically unexplained symptoms. RESULTS: 1569 papers were retrieved, which yielded 36 relevant studies after screening. 15 studies referred to healthcare workers, 13 to general population, 5 to COVID-19 patients, 2 compared medical with non-medical professionals and 1 was studying COVID-19 patients some of which were also healthcare workers. The reported prevalence of somatic symptoms ranged from 7.4% to 67.8%. Commonly seen symptoms were shortness of breath, dyspnea, palpitations and pain in arms, legs and joints. CONCLUSIONS: Our systematic review suggests that somatic symptoms are very frequent during the pandemic and are often linked to mental distress. All three population groups are affected.

Recommended diagnostic and therapeutic procedures for psychosomatic care.

Psychosomatic medicine has undergone dynamic development in the Czech Republic in recent years. The Society of Psychosomatic Medicine of the Czech Medical Association of J. E. Purkyne was founded in 2014. It develops both the professional side of this field and strives for better integration of psychosomatic care into the Czech health care system. After several years of effort, it succeeded in obtaining approval of the medical procedure code in the field of psychosomatics (909) "psychosomatic intervention". The text of Recommended Diagnostic and Therapeutic Procedures for Psychosomatic Care describes the recommended movement of the psychosomatic patient through the health care system, diagnostic categories in psychosomatic medicine and related differential diagnosis, and basic diagnostic units in psychosomatic medicine.

[The classification of dissociative disorders and bodily distress disorder: A comparison of ICD-10 and ICD-11]. / Klassifikation der dissoziativen Störungen und der Störung der körperlichen Belastung ­ ein Vergleich zwischen ICD-10 und ICD-11.

The classification of dissociative disorders and bodily distress disorder: A comparison of ICD-10 and ICD-11 Abstract. There have been some major changes in the classification of dissociative disorders in the transition from ICD-10 to ICD-11. One important revision is the elimination of the term "conversion disorder" from the grouping title as well as the omission of any appraisal of the patient´s behavior or motivation. In ICD-11, the dissociative neurological symptom disorder has gained in importance, reflected in its presentation in the first place of this category. In contrast to ICD-10, dissociative identity disorder (multiple personality disorder) has become a single disorder. Bodily distress disorder has replaced the somatoform disorders of ICD-10 and now includes neurasthenia, while hypochondria was eliminated from this category altogether. Bodily distress disorder is defined by distinct psychological features such as extreme distress but not by the presence or absence of medical findings.

[Chronic pain syndromes and other persistent functional somatic symptoms]. / Chronische Schmerzsyndrome und andere persistierende funktionelle Körperbeschwerden.

Somatic symptoms including pain are everyday human experiences. They usually result from a complex interaction of stimuli, interpretation and reaction, and are not necessarily proportional to structural damage. Persistent functional somatic symptoms can be associated with a significant impairment of quality of life and functioning, even without mental or somatic comorbidity. Dysfunctional experiences, expectancies and behavior, not only by patients but also by physicians, can increase the risk of chronification. From the outset, management should be graded with respect to the severity and biopsychosocial aspects, with thorough but cautious diagnostics and with psychoeducative, active and coping-oriented treatment.

Indonesian patient health questionnaire's clinical utility in psychiatric outpatients: Ruling out conditions per ICD-11 criteria.

This study aimed to assess the diagnostic accuracy of the Patient Health Questionnaire (PHQ) for identifying common mental disorders in an outpatient clinical psychologist office setting in Indonesia. A total of 661 outpatients from a clinical psychology office in Jakarta, Indonesia, participated in the study. The complete PHQ was administered, and its results were compared with diagnoses made by clinical psychologists based on ICD-11 criteria, including somatoform disorder (n = 6), depression (n = 117), Generalized Anxiety Disorder (GAD, n = 50), panic disorder (n = 42), bulimia nervosa (n = 2), binge eating disorder (n = 2), and other diagnoses such as OCD and BPD (n = 442). Receiver operating characteristics were computed to examine cut-off points, and optimal cut-off points based on the Youden Index were identified for somatoform disorder (PHQ-15 ≥ 13), depression (PHQ-9 ≥ 13), GAD (GAD- 7 ≥ 10), and panic disorder (PHQ-PD ≥ 7). Cut-off points for the alcohol abuse and eating disorder modules of the PHQ could not be determined due to a lack of sample, and AUC was suboptimal for PHQ-9, GAD-7, and PHQ-ED. The Indonesian PHQ demonstrated good sensitivity but low specificity in identifying somatoform disorder, depression, GAD, and panic disorders based on ICD-11 criteria among Indonesian clinical psychologist office outpatients. In the Indonesian outpatient psychiatric context, the utility of the Indonesian PHQ appeared to be most effective in ruling out diagnoses.

Self-reported anterograde memory loss in older persons that is not validated on neuropsychological assessment: Considerations for a dissociative diagnosis.

The past decade has witnessed amplified public awareness of age-related dementias. This has resulted in a dramatic rise in the number of older persons referred to memory clinics with a primary complaint of self-reported memory loss without an antecedent neurological event (e.g., stroke) who produce neuropsychological test profiles that lack evidence of such impairment. Since the latter part of the 19th century, a confusing array of changing terminology, criteria, and perceived causation have been ascribed to patients with unverified medical symptoms to implicate psychological causation. Such terms are often misperceived by laypersons as reflecting character flaws or malingering. Of import for clinical neuropsychologists, the 11th edition of the International Classification of Diseases added cognitive to symptoms eligible for a diagnosis of the modern formulation, dissociative neurological symptom disorder. One dissociative option for referrals with self-reported neurocognitive symptoms not validated on neuropsychological testing is functional memory disorder, conceived as a psychological disorder where emotional distress is plausibly related to the perceived memory loss but is of less severity than would warrant a major depressive or anxiety diagnosis. If evidence of psychological distress or behavioral impairment is not present the referral likely reflects the increased public awareness of age-related dementias interacting with the high base rate of self-perceived memory loss in the general population. In such cases, a dissociative diagnosis should be avoided as there is evidence of neither a medical nor a psychological disorder. A summary statement of not dementia or similar is likely sufficient to help the patient.

Psychobehavioral B-Criteria of Somatic Symptom Disorder Are Associated with Somatic Symptom Reporting in a Large Sample of Psychosomatic Outpatients.

Introduction: Somatic symptom disorder (SSD) as introduced by the DSM-5 is characterized by chronic somatic symptoms not fully explained by underlying pathology and accompanied by psychological factors, the diagnostic B-criteria. These cognitive, affective, and behavioral disturbances are related to increased attention to somatic symptoms. However, there is a lack of empirical evidence regarding the association between the B-criteria and high symptom reporting in clinical settings. Methods: This 12-year retrospective, cross-sectional, observational study examined 6,491 patients from a German psychosomatic outpatient center. The somatoform subscale of HEALTH-49 was used to evaluate somatic symptom reporting. Excessive health concerns and other potential criteria associated with symptom reporting were determined using the ICD-10-Symptom Rating and other HEALTH-49 subscales. Results: Regression analysis revealed that the established B-criteria for SSD were the strongest factors associated with somatic symptom reporting, with a standardized beta-coefficient of ß = 0.31 (R2 = 0.428, df = 24, F = 187.886). Other psychobehavioral factors were clearly less associated with somatic symptom reporting, such as depressive symptoms with ß = 0.15 and impaired activity and participation with ß = 0.12. Sociodemographic factors, such as age (ß = 0.16) and gender (ß = 0.12), were also independently associated with somatic symptom reporting. Conclusion: This study provides evidence for the concept of SSD related to specific B-criteria associated with somatic symptom reporting, based on a large patient sample. These results point to an important role of psychological symptomatology in patients with somatic symptoms. The findings also suggest that additional factors contribute to the reporting of somatic symptoms. Our results may inform future diagnostic criteria for SSD.

This scientific study examines the association between psychobehavioral factors and somatic symptom reporting in a large sample of psychosomatic outpatients. We investigated the association of established and possible additional psychobehavioral criteria for somatic symptom disorder (SSD) as defined in the DSM-V. The study included 6,491 patients from a psychosomatic outpatient center over a 12-year period. The participants completed self-report questionnaires to assess somatic symptom reporting and psychobehavioral factors. The results showed that the B-criteria of SSD were associated with somatic symptom reporting, indicating the validity of these criteria in clinical practice. Other psychobehavioral factors, such as depressive symptoms and impaired activity and participation, as well as sociodemographic factors such as age and gender were also associated with somatic symptom reporting but to a much lesser extent. This study has limitations, including its retrospective and cross-sectional design, reliance on self-report measures, and the need for further research using longitudinal data and clinician-rated assessments to complement self-report data. However, our research highlights the importance of psychological symptomatology in individuals who report somatic symptoms. These findings may inform future diagnostic criteria and treatment approaches for individuals with SSD and improve treatment and patient outcomes.

Psychological risk factors of somatic symptom disorder: A systematic review and meta-analysis of cross-sectional and longitudinal studies.

OBJECTIVE: Current diagnostic concepts of somatic symptom disorder (SSD) in DSM-5 and bodily distress disorder (BDD) in ICD-11 require certain psychological criteria, but researchers have called for further specification. Therefore, in a first step, this systematic review and meta-analysis aimed to summarize the current evidence on psychological factors associated with SSD/BDD and/or disorder-relevant clinical outcomes such as symptom severity and impairment. METHODS: Psychological factors were systematically searched using Pubmed, Cochrane Library and Psycinfo via EBSCO. Studies providing original data in English or German, after 2009 were included. Cross-sectional, cohort and case-control studies investigating at least one psychological factor in individuals with SSD/BDD in the context of disorder-relevant outcomes were included. RESULTS: Forty-three eligible studies (n = 3760 patients) in SSD (none in BDD) provided data on at least one psychological factor, 37 in case-control format, 10 cross-sectional and 5 longitudinal. Meta-analyses of the case-control studies found patients with SSD to be more impaired by depression (SMD = 1.80), anxiety (SMD = 1.55), health anxiety (SMD = 1.31) and alexithymia (SMD = 1.39), compared to healthy controls. Longitudinal results are scarce, mixed, and require refining, individual studies suggest self-concept of bodily weakness, anxiety and depression to be predictive for persistent SSD and physical functioning. CONCLUSION: This review provides a detailed overview of the current evidence of psychological factors in relation to SSD/BDD. Future studies on SSD and BDD should include under-studied psychological factors, such as negative affect, fear avoidance, or emotion regulation. More longitudinal studies are needed to assess the predictive value of these factors.

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.

The framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSY-PSS).

Introduction: Numerous psychological factors are believed to play a pivotal role in the development and maintenance of persistent somatic symptoms (PSS) in all fields of medicine. However, very few of these factors have been empirically investigated in relation to PSS. The aim of this study is firstly to propose a framework and define search terms for systematic reviews on the empirical evidence and diagnostic value of psychological risk factors for PSS and PSS-related outcomes (PSY-PSS). Secondly, the application of the framework is illustrated using the example of a systematic review on the relevance of psychological factors in somatic symptom disorders (SSD; DSM-5) and bodily distress disorders (BDD; ICD-11). Methods: Following a narrative review approach, two comprehensive lists of search terms to identify studies in (1) relevant patient groups with PSS and (2) relevant psychological factors were generated by reviewing the current literature and employing an iterative process of internal revision and external expert feedback. Results: We identified 83 relevant symptoms, syndromes and disorders for which we defined a total of 322 search terms (list 1). We further comprised 120 psychological factors into 42 subcategories and 7 main categories (list 2). The introduced lists can be combined to conduct systematic reviews on one or more specific psychological factors in combination with any symptom, syndrome or disorder of interest. A protocol of the application of this framework in a systematic review and meta-analysis on psychological etiological factors of SSD and BDD is presented following the PRISMA guidelines. Discussion: This framework will help to gather systematic evidence on psychological factors in order to improve the understanding of the etiology of PSS, to refine future diagnostic conceptualizations of PPS, and to develop optimized mechanism-based interventions for individuals with PPS and related syndromes and disorders.

Not a general, symptom-unspecific, transdiagnostic marker for functional symptoms: sensorimotor processing of head control is intact in chronic pain.

Introduction: Functional disorders are prevalent in all medical fields and pose a tremendous public health problem, with pain being one of the most common functional symptoms. Understanding the underlying, potentially unifying mechanism in functional (pain) disorders is instrumental in facilitating timely diagnosis, stigma reduction, and adequate treatment options. Neuroscientific models of perception suggest that functional symptoms arise due to dysregulated sensorimotor processing in the central nervous system, with brain-based predictions dominating the eventual percept. Experimental evidence for this transdiagnostic mechanism has been established in various functional symptoms. The goal of the current study was to investigate whether erroneous sensorimotor processing is an underlying transdiagnostic mechanism in chronic (functional) pain. Method: A total of 13 patients with chronic (functional) pain [three patients with chronic (functional) pain disorder, F45.40, ICD-10; 10 patients with chronic pain disorder with somatic and psychological factors, F45.41, ICD-10]; and 15 healthy controls performed large combined eye-head gaze shifts toward visual targets, naturally and with increased head moment of inertia. We simultaneously measured participants' eye and head movements to assess head oscillations at the end of the gaze shift, which are an established indicator of (transdiagnostic) sensorimotor processing deficits of head control. Results: Using a Bayesian analysis protocol, we found that patients with chronic (functional) pain and control participants stabilized their heads equally well (Bayes Factor 01 = 3.7, Bayes Factor exclusion = 5.23; corresponding to substantial evidence) during all sessions of the experiment. Conclusion: Our results suggest that patients with chronic (functional) pain do not show measurable symptom-unspecific sensorimotor processing deficits. We discuss outcome parameter choice, organ system specificity, and selection of patient diagnoses as possible reasons for this result and recommend future avenues for research.

Unstable Gaze in Functional Dizziness: A Contribution to Understanding the Pathophysiology of Functional Disorders.

Objective: We are still lacking a pathophysiological mechanism for functional disorders explaining the emergence and manifestation of characteristic, severely impairing bodily symptoms like chest pain or dizziness. A recent hypothesis based on the predictive coding theory of brain function suggests that in functional disorders, internal expectations do not match the actual sensory body states, leading to perceptual dysregulation and symptom perception. To test this hypothesis, we investigated the account of internal expectations and sensory input on gaze stabilization, a physiologically relevant parameter of gaze shifts, in functional dizziness. Methods: We assessed gaze stabilization in eight functional dizziness patients and 11 healthy controls during two distinct epochs of large gaze shifts: during a counter-rotation epoch (CR epoch), where the brain can use internal models, motor planning, and resulting internal expectations to achieve internally driven gaze stabilization; and during an oscillation epoch (OSC epoch), where, due to terminated motor planning, no movement expectations are present, and gaze is stabilized by sensory input alone. Results: Gaze stabilization differed between functional patients and healthy controls only when internal movement expectations were involved [F(1,17) = 14.63, p = 0.001, and partial η2 = 0.463]: functional dizziness patients showed reduced gaze stabilization during the CR (p = 0.036) but not OSC epoch (p = 0.26). Conclusion: While sensory-driven gaze stabilization is intact, there are marked, well-measurable deficits in internally-driven gaze stabilization in functional dizziness pointing at internal expectations that do not match actual body states. This experimental evidence supports the perceptual dysregulation hypothesis of functional disorders and is an important step toward understanding the underlying pathophysiology.

Multisensory mechanisms of body perception in somatoform disorders.

OBJECTIVE: According to one of the hypotheses, somatoform disorders (SD) are related to disturbed perception of bodily signals. We suspect that the disturbances and abnormalities of multisensory integration dynamics may be an additional SD mechanism. The objective of the research was to investigate multisensory bodily illusion dynamics in SD patients. METHODS: A clinical group of SD patients (n = 16) and a control group (n = 17) participated in experiments aimed at eliciting a visual-tactile rubber hand illusion (RHI) and a visual-kinesthetic virtual hand illusion (VHI). RESULTS: For both illusions studied, the illusion dynamics in SD patients differed from those of healthy subjects. The visual-tactile illusion on the subjective level appeared to be less strong in SD patients, and no proprioceptive drift (PD) was detected. The subjective dynamics of the visual-kinesthetic illusion in patients were similar to those of the control group, but the PD dynamics were different: after the termination of stimuli from the artificial limb, the proprioceptive system did not return to its initial state; on the contrary, PD continued to increase. CONCLUSION: In comparison with the norm, patients with somatoform disorders display differences in multisensory mechanisms underlying the development of body perception. The results suggest that the disturbance of visual-tactile integration of the stimuli represents one of the mechanisms of body perception distortion in somatoform disorders. It may be assumed that one of the reasons for persistent symptom perception in SD patients is the rigidity of multisensory stimuli perception, at least in the visual-motor domain.

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study.

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.