Mohan Isaac

Somatization, somatosensory amplification, attribution styles and illness behaviour: A review

Somatic symptoms have been conceptualized in many different ways in literature. Current classifications mainly focus on the numbers of symptoms, with relative neglect of the underlying psychopathology. Researchers have emphasized the importance of a number of experiential, perceptual and cognitive-behavioural aspects of somatization. This review focuses on existing literature on the role of somatosensory amplification, attribution styles, and illness behaviour in somatization. Evidence suggests that somatosensory amplification is neither sensitive nor specific to somatizing states, and that other factors like anxiety, depression, neuroticism, alexithymia may also have an influence. Attribution research supports the existence of multiple causal attributions, which are related to the numbers of somatic symptoms. While somatizing patients have more organic attributions, depressed patients have more psychological attributions. A global somatic attribution style is associated with the number of obscure somatic symptoms, while a psychological attribution style is associated with both—psychological and somatic— symptoms of depression and anxiety. There are conflicting findings with respect to the role of normalizing attributions in reducing physician recognition of anxiety and depression. Specific symptom attributions appear to explain physician recognition of psychological distress, but global attribution styles do not appear to explain any further variance in physician recognition beyond that explained by specific causal attributions. Illness behaviour has been studied in two distinct ways in literature. Research focusing on attendance rates as a form of illness behaviour suggests that somatization is associated with high levels of health care utilization. There is also some evidence that health care utilization, amplification and attributions styles may be interrelated among somatizing patients. More structured ways to assess illness behaviour have found high levels of abnormal illness behaviour in this population. Overall, research appears to suggest a complex (and as yet unclear) relationship between somatic symptoms and underlying cognitions/illness behaviours. While it is clear that somatization is closely related to a number of perceptual and cognitive-behavioural factors, the precise nature of these relationships are yet to be elucidated.

Risk factors for completed suicides: a case-control study from Bangalore, India

Introduction. Suicides are a hidden and unrecognized epidemic in the Indian region, affecting predominantly younger age groups. Information on causative risk factors and mechanisms is not available in the country, which is crucial for designing intervention programmes. Objectives. To identify and quantify risk factors for completed suicides in the city of Bangalore. Methods. A case–control study was conducted with the families of 269 completed suicides and 269 living controls within the broader population of the city using psychological autopsy methods. Results. The study has shown that several factors in the areas of family, marriage, education, occupation, general health, mental health and absence of protective factors contribute significantly for suicides. The cumulative and repetitive interaction of several factors in a complex manner results in suicides. The significant factors were presence of previous suicidal attempt in self (odds ratio (OR) = 42.62), interpersonal conflicts and marital disharmony with spouse (OR = 27.98), alcoholism in self (OR = 23.38), presence of a mental illness (OR = 11.07), sudden economic bankruptcy (OR = 7.1), domestic violence (OR = 6.82) and unemployment (OR = 6.15). Individuals completing suicides did not have a positive outlook towards life, problem-solving approaches and coping skills. Conclusion. The observed findings are at variance with suicidal causation in the West in some areas operating in a different sociocultural and economic environment. The intervention strategies should include prioritized macro and micro level efforts aimed at individual, family and society.

Are somatoform disorders 'mental disorders'? A contribution to the current debate

Purpose of review During the last 2 years, a debate has started over whether the somatoform symptoms/medically unexplained symptoms are wrongly placed under the category of mental disorders (section F in International classification of diseases-10 and in Diagnostic and statistical manual for mental disorders-IV). Recent findings Most experts on medically unexplained symptoms agree that there is a substantial need for revision of the diagnoses of somatoform disorders. While some authors suggest moving the somatoform disorders from axis I to axis III, others suggest improving the classification of these syndromes on axis I, such as by using empirically derived criteria and by introducing psychological descriptors which justify the categorization as a mental disorder. In contrast to the situation when the last version of Diagnostic and statistical manual for mental disorders was published, new empirical data has shown some psychological and behavioural characteristics of patients with somatoform symptoms. These and other empirically founded approaches can be landmarks for the revision of this section in Diagnostic and statistical manual for mental disorders-V and International classification of diseases-11. Summary The classification of somatoform disorders as ‘mental disorders’ could be justified if empirically founded psychological and behavioural characteristics are included into the classification process. Attention focusing, symptom catastrophizing, and symptom expectation are outlined as possible examples of involved psychological processes.

Global, national, and local approaches to mental health: examples from India.

Neuropsychiatric disorders and suicide amount to 12.7% of the global burden of disease and related conditions (GBD) according to World Health Organization (WHO) estimates for 1999, and recognition of the enormous component of mental illness in the GBD has attracted unprecedented attention in the field of international health. Focusing on low‐ and middle‐income countries with high adult mortality, this article discusses essential functions of international agencies concerned with mental health. A review of the history and development of national mental health policy in India follows, and local case studies consider the approach to planning in a rural mental health programme in West Bengal and the experience in an established urban mental health programme in a low‐income community of Mumbai. Local programmes must be attentive to the needs of the communities they serve, and they require the support of global and national policy for resources and the conceptual tools to formulate strategies to meet those needs. National programmes retain major responsibilities for the health of their country’s population: they are the portals through which global and local interests, ideas, and policies formally interact. International priorities should be responsive to a wide range of national interests, which in turn should be sensitive to diverse local experiences. Mental health actions thereby benefit from the synergy of informed and effective policy at each level.

Towards better understanding and management of somatoform disorders

Much research has recently been conducted on somatoform disorders demonstrating their clinical importance, associated health-service burden and economic cost. These conditions are often comorbid with other mental and physical disorders and particularly prevalent in primary care and general medical settings. Although culture-specific manifestations and variations of somatization occur—it is now accepted that medically unexplained somatic symptoms are a universal phenomenon. The management of somatoform disorders is generally a complex and lengthy process; however, a number of recent studies have demonstrated the effectiveness of short-term treatments such as cognitive behaviour therapy and educational interventions. Despite advances in their understanding and treatment, debate still surrounds the conceptualization and categorization of somatoform disorders, with a number of experts proposing a complete revaluation and reassignment of this diagnostic classification category. The following paper represents a review of recently published literature on frequency, characteristics, conceptualization, impact and management of somatoform disorders.

Amplification and Attribution Styles in Somatoform and Depressive Disorders – A Study from Bangalore, India

Objective: The present investigation aimed to study attribution styles and somatosensory amplification among patients suffering from somatoform and depressive disorders. Methods: Two groups of 30 patients with diagnoses of somatoform disorder and depressive disorder, respectively (ICD-10 DCR), and one group of 30 normal controls were recruited. The study patients were assessed using the symptom interpretation questionnaire, somatosensory amplification scale, and scales for assessing alexithymia and illness attitudes. Results: The somatoform and depressive disorder patients had greater recent symptom experience than the normal group. The somatoform disorder group had higher somatic attribution scores, the depressive disorder sample had higher psychological attribution scores, and the normal group had higher normalizing attribution scores than the two other groups. Somatoform disorder patients had higher mean amplification scores than depressed patients, who in turn had higher scores than normals. Correlation analyses showed somatic attribution and certain illness attitudes to be closely associated in all three groups. Recent symptom experience was associated with amplification in the somatoform disorder group alone. Recent symptom experience, a diagnosis of somatoform disorder and lower normalizing attribution scores predicted amplification. Discussion: These findings indicate that somatoform and depressive disorder patients and normals differ from each other in their attribution styles. There is a clustering of attributes among somatoform disorder patients that include greater symptom experience, which is somatically attributed, and is associated with excessive illness worry, concern and preoccupation with bodily symptoms, and a fear of having or developing a disease. On the other hand, depressed patients and normal subjects who do have a somatic attribution style (though, as a group, they have lower somatic attribution scores than the somatoform disorder group), also harbor hypochondriacal beliefs and related attitudes.

Dissociative and conversion disorders: defining boundaries

Purpose of review Although dissociative disorders have been described and diagnosed for some time, their aetiology, pathogenesis, phenomenology and management continues to arouse debate. It is only in recent times that researchers have made some progress by integrating trauma related theories with more contemporary cognitive theories and neurobiology. Recent findings Dissociation as a phenomenon is reported to occur in a variety of disorders. This widespread occurrence has contributed to a better understanding of dissociation. An expansion of this concept may have contributed to the loss of its original significance. Recent studies in the field of dissociation that pertain to its aetiology, pathophysiology, neurobiology and management are critically reviewed. Summary Dissociative disorder is conceptually a difficult disorder to study. Apart from exposure to trauma, certain primary personality attributes may contribute to the propensity to develop dissociative disorder. Recent advances in functional neuroimaging facilitated by enhanced knowledge in the neural representation of body state have helped to improve our understanding of dissociation. There is confusion over the use of various terms such as sexual abuse and physical abuse in explaining causality. Current classificatory systems have not been found suitable when applied across cultures. In spite of all of these limitations, there has been recent progress toward a better understanding of dissociative disorders.

Post-traumatic stress disorder and terrorism

Purpose of review Terrorist attacks are increasing in different parts of the world. The psychiatric consequences of terrorist attacks, particularly post-traumatic stress disorders, are often underrated. Recent terrorist attacks, particularly the attacks of September 11, 2001 in the USA, focused attention on post-traumatic stress disorder. This review examines the prevalence rates and characteristics of post-traumatic stress disorder after terrorist attacks. Recent findings At least 28-35% of people exposed to a terrorist attack may develop post-traumatic stress disorder. Whereas persons directly exposed to terrorist attacks have a greater risk of developing post-traumatic stress disorder, the secondary effects of vicarious exposure on people not directly exposed are significant. Individuals with post-traumatic stress disorder have higher healthcare utilization and medication use. More than 40% of people across the USA experienced substantial symptoms of stress after the attacks of September 11, 2001. The rates of acute post-traumatic stress disorder and depression among residents of lower Manhattan, New York, were twice the baseline rate 5-8 weeks after the attacks. The presence of pre-existing stressors, levels of social support, female sex, and Hispanic ethnicity were important predictors of post-traumatic stress disorder. Disaster-related television viewing could be harmful for children. The role of psychological debriefing in the prevention of post-traumatic stress disorder is questionable. Summary Most suffers of post-traumatic stress disorder are reluctant to see mental health professionals. Primary care physicians are best suited to identify and manage individuals with post-traumatic stress disorder. There is a need to train primary care practitioners in the identification and management of the psychiatric consequences of trauma and terrorism.

Behavioural interventions to reduce the risk of physical illness in persons living with mental illness

Purpose of review It is beyond dispute that people living with mental illness suffer a disproportionate disease burden when compared with people in the general population. This review considers the efficacy and effectiveness of lifestyle behavioural interventions at service delivery level as a strategy to reduce the risk factors that contribute to somatic disease comorbidity. As many factors contribute to the very poor physical health of people living with mental illness and as there are no ‘quick fix’ remedies, strategies to improve physical health need to be sustainable on a system-wide basis. Recent findings Most studies of behavioural interventions at best report modest success during the period of the intervention. However, even limited success can significantly reduce the likelihood of physical comorbidities developing. Unfortunately, the evidence suggests that any gains during the intervention are mostly lost over time. The implication is that interventions need to be sustainable over the long-term. Summary When planning behavioural interventions, consideration ought to be given to extending them over a period of years not weeks or months. Approaches that include additional on-going support beyond the intervention period itself promote a greater likelihood of maintaining the improved physical health of the target population.

The future of somatoform disorders: Somatic symptom disorder, bodily distress disorder or functional syndromes?

People suffering from medically unexplained usually hard to change, and therefore it should be physical symptoms represent the largest group of patients in psychosomatic and behavioural medicine, and therefore, their classification is of pivotal relevance. The psychiatric classification systems of the last decades used the concept of ‘somatoform disorders’ to identify this patient group. However, the classification and labelling of somatoform disorders has been a point of discussion since its introduction in 1980 [1]. Although subsequent revisions introduced only minor modifications, DSM-5 brings some substantial changes of this category, and also suggests relabelling somatoform disorders to ‘somatic symptom disorder’ (SSD). In this article, we will discuss whether SSD solves the existing problems around the concept of somatoform disorders. We will also discuss two alternatives with their pros and cons, namely the bodily distress disorder concept originally introduced by Per Fink and colleagues [2] and which is a concept that found the sympathies of the ICD-11 working group, but we will also discuss the traditional concept of functional syndromes which still benefits from its high acceptance in nonpsychiatric fields of medicine.