Katharina Voigt

Towards positive diagnostic criteria: A systematic review of somatoform disorder diagnoses and suggestions for future classification

OBJECTIVES The classification of somatoform disorders is currently being revised in order to improve its validity for the DSM-V and ICD-11. In this article, we compare the validity and clinical utility of current and several new diagnostic proposals of those somatoform disorders that focus on medically unexplained somatic symptoms. METHODS We searched the Medline, PsycInfo, and Cochrane databases, as well as relevant reference lists. We included review papers and original articles on the subject of somatoform classification in general, subtypes of validity of the diagnoses, or single diagnostic criteria. RESULTS Of all diagnostic proposals, only complex somatic symptom disorder and the Conceptual Issues in Somatoform and Similar Disorders (CISSD) example criteria reflect all dimensions of current biopsychosocial models of somatization (construct validity) and go beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated. However, the number of somatic symptoms has been found to be a strong predictor of disability. Some evidence indicates that psychological symptoms can predict disease course and treatment outcome (e.g., therapeutic modification of catastrophizing is associated with positive outcome). Lengthy symptom lists, the requirement of lifetime symptom report (as in abridged somatization), complicated symptom patterns (as in current somatization disorder), and imprecise definitions of diagnostic procedures (e.g., missing symptom threshold in complex somatic symptom disorder) reduce clinical utility. CONCLUSION Results from the reviewed studies suggest that, of all current and new diagnostic suggestions, complex somatic symptom disorder and the CISSD definition appear to have advantages regarding validity and clinical utility. The integration of psychological and behavioral criteria could enhance construct and descriptive validity, and confers prospectively relevant treatment implications. The incorporation of a dimensional approach that reflects both somatic and psychological symptom severity also has the potential to improve predictive validity and clinical utility.

Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5

OBJECTIVE Current diagnostic criteria for somatoform disorders demand revisions due to their insufficient clinical as well as scientific usability. Various psychological and behavioral characteristics have been considered for the proposed new category Somatic Symptom Disorder (SSD). With this study, we were able to jointly assess the validity of these variables in an inpatient sample. METHODS Using a cross-sectional design, we investigated N=456 patients suffering from somatoform disorder, anxiety, or depression. Within one week after admission to the hospital, informed consent was obtained and afterwards, a diagnostic interview and a battery of self-report questionnaires were administered. Logistic regression analyses were performed to determine which variables significantly add to construct and descriptive validity. RESULTS Several features, such as somatic symptom severity, health worries, health habits, a self-concept of being weak, and symptom attribution, predicted physical health status in somatization. Overall, our model explained about 50% of the total variance. Furthermore, in comparison with anxious and depressed patients, health anxiety, body scanning, and a self-concept of bodily weakness were specific for DSM-IV somatoform disorders and the proposed SSD. CONCLUSIONS The present study supports the inclusion of psychological and behavioral characteristics in the DSM-5 diagnostic criteria for somatoform disorders. Based on our results, we make suggestions for a slight modification of criterion B to enhance construct validity of the Somatic Symptom Disorder.

Development and Validation of the Somatic Symptom Disorder-B Criteria Scale (SSD-12).

Objective To develop and validate a new self-report questionnaire for the assessment of the psychological features of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition somatic symptom disorder. Methods The Somatic Symptom Disorder–B Criteria Scale (SSD-12) was developed in several steps from an initial pool of 98 items. The SSD-12 is composed of 12 items; each of the three psychological subcriteria is measured by four items. In a cross-sectional study, the SSD-12 was administered to 698 patients (65.8% female, mean [standard deviation] age = 38.79 [14.15] years) from a psychosomatic outpatient clinic. Item and scale characteristics as well as measures of reliability and validity were determined. Results The SSD-12 has good item characteristics and excellent reliability (Cronbach &agr; = .95). Confirmatory factor analyses suggested that a three-factorial structure that reflects the three psychological criteria interpreted as cognitive, affective, and behavioral aspects (n = 663, Comparative Fit Index > 0.99, Tucker-Lewis Index > 0.99, Root Mean Square Error of Approximation = 0.06, 90% confidence interval = 0.01-0.08). SSD-12 total sum score was significantly associated with somatic symptom burden (r = 0.47, p < .001) and health anxiety (r = 0.71, p < .001), and moderately associated with general anxiety (r = 0.35, p < .001) and depressive symptoms (r = 0.22, p < .001). Patients with a higher SSD-12 psychological symptom burden reported higher general physical and mental health impairment and significantly higher health care use. Conclusions The SSD-12 is the first self-report questionnaire that operationalizes the new psychological characteristics of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition somatic symptom disorder. Initial assessment indicates that the SSD-12 has sufficient reliability and validity to warrant further testing in both research and clinical settings.

Suicidality in primary care patients with somatoform disorders

Objective To examine rates of suicidality in primary care patients with somatoform disorders and to identify factors that might help to understand and manage active suicidal ideation in these patients. Methods We conducted a cross-sectional study screening 1645 primary care patients. In total, 142 patients fulfilled the criteria for a somatoform disorder. Suicidality and illness perceptions were assessed in these patients. Results Of the 142 patients, 23.9% had active suicidal ideation during the previous 6 months; 17.6% had attempted to commit suicide in the past, the majority after onset of the somatoform symptoms. We tested two models with suicidal ideation as a dependent variable. In the first model, comorbid symptoms of depression (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03–1.33) and previous suicide attempts (OR= 3.02, 95% CI = 1.06–8.62) were significantly associated with suicidal ideation. Comorbid symptoms of anxiety did not yield significance. Illness perceptions and age of onset of the symptoms were then added to this model to test the role of somatoform-specific factors in addition to previous factors. In the complete model, comorbid symptoms of depression (OR = 1.15, 95% CI = 1.00–1.32) and dysfunctional illness perceptions (OR = 1.06, 95% CI = 1.01–1.11) were independently associated with active suicidal ideation, whereas the other factors did not yield significance. Conclusions According to our data, suicidality seems to be a substantial problem in primary care patients with somatoform disorders. Dysfunctional illness perceptions may play a vital role in the understanding and management of active suicidal ideation in these patients, in addition to more established factors.

Health-related quality of life, depression, and anxiety in patients with autoimmune hepatitis

BACKGROUND & AIMS Improving health related quality of life (HrQoL) in patients with chronic diseases such as autoimmune hepatitis (AIH) should be a major treatment goal. However, little is known on the HrQoL in patients with AIH, and the topic is not given attention in current practice guidelines. We therefore conducted a single center study evaluating HrQoL in 103 consecutive outpatients with AIH. METHODS Patient-reported HrQoL data were analysed in relation to clinical disease parameters and compared to representative data of the German population as well as control patients. RESULTS Based on patient-reported data, a major depressive syndrome (10.8%) was found to be five times more frequent in AIH patients compared to the general population (p<0.001). The rate of severe symptoms of anxiety was also found to be significantly increased compared to the general population (p=0.006). In seven of the eleven patients who scored for a major depressive syndrome a psychiatric comorbidity had not been diagnosed before. Major factors associated with depression and anxiety were concerns with regard to the progression of the liver disease. CONCLUSIONS This study identified--for the first time--a high rate of previously unrecognized severe symptoms of depression and anxiety in patients with AIH. Of importance for daily clinical practice, the factors associated with these symptoms may in part be amenable to targeted counselling and adequate treatment of the disease, thereby offering the chance to improve the care and HrQoL of AIH-patients.

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder: Prospective 1-year follow-up study

OBJECTIVE To compare the predictive validity and clinical utility of DSM-IV somatoform disorders and DSM-5 Somatic Symptom Disorder (SSD) at 12-month follow-up. METHODS In a sample of psychosomatic inpatients (n=322, mean age=45.6 years (SD 10.0), 60.6% females) we prospectively investigated DSM-IV somatoform disorders and the DSM-5 diagnosis of SSD plus a variety of psychological characteristics, somatic symptom severity, and health-related quality of life at admission, discharge, and follow-up. RESULTS DSM-IV diagnoses and DSM-5 SSD similarly predicted physical functioning at follow-up; SSD also predicted mental functioning at follow-up. Bodily weakness, intolerance of bodily complaints, health habits, and somatic attribution at admission were significant predictors of physical functioning at follow-up. The change in physical functioning during inpatient therapy was a significant predictor for the course of physical functioning until follow-up. CONCLUSIONS Psychological symptoms appear to be predictively valid diagnostic criteria for the 12-month functional outcome in patients with SSD. Mental functioning can be better predicted by the DSM-5 diagnosis than by DSM-IV diagnoses. Not the change in single psychological features but in physical functioning during the treatment interval predicted the change in physical functioning until follow-up.

Psychological and interactional characteristics of patients with somatoform disorders: Validation of the Somatic Symptoms Experiences Questionnaire (SSEQ) in a clinical psychosomatic population

OBJECTIVE The new DSM-5 Somatic Symptom Disorder (SSD) emphasizes the importance of psychological processes related to somatic symptoms in patients with somatoform disorders. To address this, the Somatic Symptoms Experiences Questionnaire (SSEQ), the first self-report scale that assesses a broad range of psychological and interactional characteristics relevant to patients with a somatoform disorder or SSD, was developed. This prospective study was conducted to validate the SSEQ. METHODS The 15-item SSEQ was administered along with a battery of self-report questionnaires to psychosomatic inpatients. Patients were assessed with the Structured Clinical Interview for DSM-IV to confirm a somatoform, depressive, or anxiety disorder. Confirmatory factor analyses, tests of internal consistency and tests of validity were performed. RESULTS Patients (n=262) with a mean age of 43.4 years, 60.3% women, were included in the analyses. The previously observed four-factor model was replicated and internal consistency was good (Cronbachs α=.90). Patients with a somatoform disorder had significantly higher scores on the SSEQ (t=4.24, p<.001) than patients with a depressive/anxiety disorder. Construct validity was shown by high correlations with other instruments measuring related constructs. Hierarchical multiple regression analyses showed that the questionnaire predicted health-related quality of life. Sensitivity to change was shown by significantly higher effect sizes of the SSEQ change scores for improved patients than for patients without improvement. CONCLUSION The SSEQ appears to be a reliable, valid, and efficient instrument to assess a broad range of psychological and interactional features related to the experience of somatic symptoms.

Der Fragebogen zum Erleben von Körperbeschwerden (SSEQ): Ein neues Selbstbeurteilungsinstrument zur Erfassung der psychischen Merkmale somatoformer Störungen

Psychological symptoms of somatoform disorders will be part of their new definition in DSM-5. We developed the Somatic Symptoms Experiences Questionnaire (SSEQ) as a self-report questionnaire to assess important psychological characteristics of patients with somatoform disorders. Item selection and identification of factor structure, as well as reliability and validity have been checked in a sample of N=453 psychsomatic outpatients. Results of a principal components analysis with Promax-rotation suggested 4 factors (health worries, illness experience, difficulties in interaction with doctors, impact of illness). Validity analyses confirmed associations between the SSEQ-Scores and the physical disability of patients. Although further assessments of psychometric qualities are needed, the questionnaire appears to be well-suited for future assessment of relevant psychological features of somatoform disorders.

Public Familiarity With the Terms Somatoform Disorder and Functional Disorder in Germany: Results From a Representative Population Survey

OBJECTIVE The terms somatoform disorder and functional disorder have been criticized for hindering rather than facilitating clinical communication, and physicians may rarely use these terms when communicating with patients who might be eligible for these diagnoses. However, no study has yet examined the extent to which patients at risk for these disorders are familiar with the diagnostic terms. Therefore, the primary aim of this study was to examine whether people at risk for a somatoform disorder (ie, those with medically unexplained somatic symptoms) are more familiar with the 2 terms than others. METHOD Participants in a representative German population sample (N = 2,471) were asked whether they were familiar with the terms somatoform disorder and functional disorder. The mean (SD) age of the sample was 50.5 (18.6) years, and 53.9% were women. Sociodemographic variables, (unexplained) physical ailments, doctor visits, depression, and anxiety were also assessed. Data were collected from November 2009 to December 2009. RESULTS Of the sample, 19.5% and 54.0% reported being familiar with the terms somatoform disorder and functional disorder, respectively. Participants with medically unexplained symptoms did not have a higher probability of knowing the terms somatoform disorder (odds ratio = 0.98, 95% CI = 0.57-1.68) or functional disorder (odds ratio = 1.32, 95% CI = 0.86-2.04) compared to all others. CONCLUSIONS Participants with a potential somatoform disorder did not differ in their familiarity ratings from others. We conclude that these diagnostic terms are probably not commonly used by physicians in routine clinical communication with patients suffering from unexplained medical symptoms. Future empirical research should investigate whether the currently proposed diagnosis complex somatic symptom disorder can solve current problems of acceptability, communication, and adequate treatment.