Same same, but different: effects of likelihood framing on concerns about a medical disease in patients with somatoform disorders, major depression, and healthy people.

BACKGROUND: Research has shown that patients with somatoform disorders (SFD) have difficulty using medical reassurance (i.e. normal results from diagnostic testing) to revise concerns about being seriously ill. In this brief report, we investigated whether deficits in adequately interpreting the likelihood of a medical disease may contribute to this difficulty, and whether patients' concerns are altered by different likelihood framings. METHODS: Patients with SFD (N = 60), patients with major depression (N = 32), and healthy volunteers (N = 37) were presented with varying likelihoods for the presence of a serious medical disease and were asked how concerned they are about it. The likelihood itself was varied, as was the format in which it was presented (i.e. negative framing focusing on the presence of a disease v. positive framing emphasizing its absence; use of natural frequencies v. percentages). RESULTS: Patients with SFD reported significantly more concern than depressed patients and healthy people in response to low likelihoods (i.e. 1: 100 000 to 1:10), while the groups were similarly concerned for likelihoods ⩾1:5. Across samples, the same mathematical likelihood caused significantly different levels of concern depending on how it was framed, with the lowest degree of concern for a positive framing approach and higher concern for natural frequencies (e.g. 1:100) than for percentages (e.g. 1%). CONCLUSIONS: The results suggest a specific deficit of patients with SFD in interpreting low likelihoods for the presence of a medical disease. Positive framing approaches and the use of percentages rather than natural frequencies can lower the degree of concern.

The Amplification of Symptoms in the Medically Ill.

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

How the integration of normal medical test results can be improved in patients with somatoform disorders-An experimental study.

BACKGROUND: We examined whether the difficulties of patients with somatoform disorders (SFDs) in integrating medical reassurance can be altered by preventing patients from devaluing reassuring information through defensive cognitive strategies. METHOD: Patients with SFD (n = 60), patients with major depression (n = 32), and healthy volunteers (n = 37) watched a videotaped doctor's report, which provided medical reassurance for gastroenterological complaints. Subsequently, participants were asked about their perception of the report. In the SFD sample, patients' appraisal of the reassuring was experimentally modulated: In one condition, doubts about the validity of the doctor's diagnostic assessment were triggered; in another condition, the devaluation of medical reassurance was blocked through underscoring the validity of the doctor's diagnostic assessment; and a control condition received no manipulation. RESULTS: As evident on all outcome variables, patients with SFD had more difficulty integrating medical reassurance than depressed and healthy people. Within the SFD sample, participants from the experimental condition blocking the devaluation of medical reassurance rated the likelihood of an undetected serious disease to be significantly lower than the other two conditions. They also reported less emotional concern and a lower desire to seek the opinion of another doctor. CONCLUSIONS: By comparing patients with SFD to both a healthy and a clinical control group, the current study suggests that the difficulty in processing reassuring medical information is a specific psychopathological feature of SFD. Furthermore, our results suggest that the integration of medical reassurance can be improved by preventing patients from devaluing reassuring information through dismissive cognitive strategies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Differential Treatment Response Between Hypochondriasis With and Without Prominent Somatic Symptoms.

Background: Health anxiety may exist with or without prominent somatic symptoms, but the impact of somatic symptoms on treatment response is unclear. The study objective was to examine this question further as symptom burden may impact choice of type of treatment. Methods: This exploratory study used a unique database from a prior trial of 193 individuals with DSM-IV hypochondriasis who had been randomly assigned to either cognitive behavioral therapy, fluoxetine, combined therapy, or placebo. Two subgroups were newly defined-no/low somatic burden (n = 42) and prominent somatic burden (n = 151). Response was defined by ≥30% improvement in hypochondriasis. Results: Among high somatic hypochondriacal participants, compared to placebo, the odds of being a responder were significantly greater among those who received fluoxetine, either alone (OR = 4.46; 95% CI: 1.38, 14.41) or with cognitive behavioral therapy (OR = 3.56; 95% CI: 1.19, 10.68); the estimated odds were not significantly different for those receiving cognitive behavioral therapy alone (OR = 1.81; 95% CI: 0.59, 5.54). In contrast, among low somatic hypochondriacal participants, compared to placebo, the observed odds of being a responder were similar in magnitude and direction for those who received cognitive behavioral therapy, either alone (OR = 3.00; 95% CI: 0.38, 23.68) or in combination with fluoxetine (OR = 3.60; 95% CI: 0.62, 21.03), compared to the odds for those receiving fluoxetine alone (OR = 0.90; 95% CI: 0.14, 5.65). High somatic hypochondriacal individuals assigned to any fluoxetine group had significantly greater odds of being a responder than those who had not received fluoxetine (OR = 2.70; 95% CI: 1.33, 5.48). Low somatic hypochondriacal individuals assigned to any cognitive behavioral therapy group had significantly greater odds of being a responder than those who had not received cognitive behavioral therapy (OR = 8.03; 95% CI: 1.41, 45.67). Conclusion: These findings indicate that somatic symptom burden may be important in guiding treatment selection among individuals with marked health anxiety, as hypochondriacal individuals with high somatic burden responded more often to fluoxetine while those with low somatic burden responded more often to cognitive behavioral therapy. Systematic replication with larger studies is needed.

Mindfulness and Interoceptive Exposure Therapy for Anxiety Sensitivity in Atrial Fibrillation: A Pilot Study.

Atrial fibrillation is the most common cardiac arrhythmia and symptoms overlap with physiological sensations of anxiety. Patients with atrial fibrillation can demonstrate anxiety sensitivity even in the absence of actual atrial fibrillation symptoms. Interoceptive exposure is effective in treating anxiety sensitivity, and recently, mindfulness has been proposed as an enhancement strategy to facilitating inhibitory learning in exposure therapy. This pragmatic study piloted a brief mindfulness and interoceptive exposure treatment for anxiety sensitivity in atrial fibrillation. Eight participants with atrial fibrillation and elevated anxiety sensitivity from a hospital cardiology department participated in the treatment. Anxiety sensitivity significantly decreased during the course of the intervention. These initial findings show proof of concept for this brief intervention in a cardiac-specific behavioral medicine setting.

Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts.

Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.

Illness Anxiety Disorder: Psychopathology, Epidemiology, Clinical Characteristics, and Treatment.

Illness anxiety disorder is a primary disorder of anxiety about having or developing a serious illness. The core feature is the cycle of worry and reassurance seeking regarding health, as opposed to a focus on relief of distress caused by somatic symptoms (as in Somatic Symptom Disorder). Clinically significant health anxiety is common, with estimates ranging up to 13% in the general adult population. There are evidence-based treatments, including psychopharmacology and cognitive behavioral therapy, that can significantly alleviate symptoms. An understanding of the core psychopathology and clinical features of illness anxiety disorder is essential to fostering a working alliance with patients with health anxiety, as is the maintenance of an empathic, curious, and nonjudgmental stance toward their anxiety. Collaboration between medical providers is essential to avoid the pitfalls of excess testing and medical treatment.

A Randomized Controlled Trial of Medication and Cognitive-Behavioral Therapy for Hypochondriasis.

OBJECTIVE: Prior studies of hypochondriasis demonstrated benefits for pharmacotherapy and for cognitive-behavioral therapy (CBT). This study examined whether joint treatment offers additional benefit. METHOD: Patients with DSM-IV hypochondriasis (N=195) were randomly assigned to one of four treatments-placebo, CBT, fluoxetine, or joint treatment with both fluoxetine and CBT. Evaluations assessed hypochondriasis, other psychopathology, adverse events, functional status, and quality of life. The primary analysis assessed outcome at week 24 among the intent-to-treat sample, with responders defined as having a 25% or greater improvement over baseline on both the Whiteley Index and a modified version of the Yale-Brown Obsessive Compulsive Scale for hypochondriasis (H-YBOCS-M). The Cochran-Armitage trend test assessed the hypothesized pattern of response: joint treatment > CBT or fluoxetine treatment > placebo treatment. RESULTS: The predicted pattern of response was statistically significant, as shown by the following responder rates: joint treatment group, 47.2%; single active treatment group, 41.8%; and placebo group, 29.6%. Responder rates for each active treatment were not significantly different from the rate for placebo. Secondary analyses of the Whiteley Index as a continuous measure revealed that, compared with placebo, fluoxetine (but not CBT) was significantly more effective at week 24 in reducing hypochondriasis and had a significantly faster rate of improvement over 24 weeks. Fluoxetine also resulted in significantly less anxiety and better quality of life than placebo. Dropout rates did not differ between groups, and treatment-emergent adverse events were evenly distributed. CONCLUSIONS: This study supports the safety, tolerance, and efficacy of fluoxetine for hypochondriasis. Joint treatment provided a small incremental benefit. Because approximately 50% of patients did not respond to the study treatments, new or more intensive approaches are needed.

Cingulo-insular structural alterations associated with psychogenic symptoms, childhood abuse and PTSD in functional neurological disorders.

OBJECTIVE: Adverse early-life events are predisposing factors for functional neurological disorder (FND) and post-traumatic stress disorder (PTSD). Cingulo-insular regions are implicated in the biology of both conditions and are sites of stress-mediated neuroplasticity. We hypothesised that functional neurological symptoms and the magnitude of childhood abuse would be associated with overlapping anterior cingulate cortex (ACC) and insular volumetric reductions, and that FND and PTSD symptoms would map onto distinct cingulo-insular areas. METHODS: This within-group voxel-based morphometry study probes volumetric associations with self-report measures of functional neurological symptoms, adverse life events and PTSD symptoms in 23 mixed-gender FND patients. Separate secondary analyses were also performed in the subset of 18 women with FND to account for gender-specific effects. RESULTS: Across the entire cohort, there were no statistically significant volumetric associations with self-report measures of functional neurological symptom severity or childhood abuse. In women with FND, however, parallel inverse associations were observed between left anterior insular volume and functional neurological symptoms as measured by the Patient Health Questionnaire-15 and the Screening for Somatoform Symptoms Conversion Disorder subscale. Similar inverse relationships were also appreciated between childhood abuse burden and left anterior insular volume. Across all subjects, PTSD symptom severity was inversely associated with dorsal ACC volume, and the magnitude of lifetime adverse events was inversely associated with left hippocampal volume. CONCLUSIONS: This study reveals distinct cingulo-insular alterations for FND and PTSD symptoms and may advance our understanding of FND. Potential biological convergence between stress-related neuroplasticity, functional neurological symptoms and reduced insular volume was identified.

Avoidance in hypochondriasis.

UNLABELLED: The DSM-5 diagnosis of illness anxiety disorder adds avoidance as a component of a behavioral response to illness fears - one that was not present in prior DSM criteria of hypochondriasis. However, maladaptive avoidance as a necessary or useful criterion has yet to be empirically supported. METHODS: 195 individuals meeting DSM-IV criteria for hypochondriasis based on structured interview completed a variety of self-report and clinician-administered assessments. Data on maladaptive avoidance were obtained using the six-item subscale of the clinician-administered Hypochondriasis - Yale Brown Obsessive Compulsive Scale - Modified. To determine if avoidance emerged as a useful indicator in hypochondriasis, we compared the relative fit of continuous latent trait, categorical latent class, and hybrid factor mixture models. RESULTS: A two-class factor mixture model fit the data best, with Class 1 (n=147) exhibiting a greater level of severity of avoidance than Class 2 (n=48). The more severely avoidant group was found to have higher levels of hypochondriacal symptom severity, functional impairment, and anxiety, as well as lower quality of life. CONCLUSION: These results suggest that avoidance may be a valid behavioral construct and a useful component of the new diagnostic criteria of illness anxiety in the DSM-5, with implications for somatic symptom disorder.

Benzodiazepines are Prescribed More Frequently to Patients Already at Risk for Benzodiazepine-Related Adverse Events in Primary Care.

BACKGROUND: Benzodiazepine use is associated with adverse drug events and higher mortality. Known risk factors for benzodiazepine-related adverse events include lung disease, substance use, and vulnerability to fracture. OBJECTIVE: To determine whether benzodiazepine prescribing is associated with risk factors for adverse outcomes. DESIGN: Longitudinal cohort study between July 1, 2011, and June 30, 2012. PARTICIPANTS: Patients who visited hospital- and community-based practices in a primary care practice-based research network. MAIN MEASURES: Odds ratio of having a target medical diagnosis for patients who received standard and high-dose benzodiazepine prescriptions; rates per 100 patients for outpatient and emergency department visits and hospitalizations. KEY RESULTS: Among 65,912 patients, clinicians prescribed at least one benzodiazepine to 15 % (9821). Of benzodiazepine recipients, 5 % received high doses. Compared to non-recipients, benzodiazepine recipients were more likely to have diagnoses of depression (OR, 2.7; 95 % CI, 2.6-2.9), substance abuse (OR, 2.2; 95 % CI, 1.9-2.5), tobacco use (OR, 1.7; 95 % CI, 1.5-1.8), osteoporosis (OR, 1.6; 95 % CI, 1.5-1.7), chronic obstructive pulmonary disease (OR, 1.6; 95 % CI, 1.5-1.7), alcohol abuse (OR, 1.5; 95 % CI, 1.3-1.7), sleep apnea (OR, 1.5; 95 % CI, 1.3-1.6), and asthma (OR, 1.5; 95 % CI, 1.4-1.5). Compared to low-dose benzodiazepine recipients, high-dose benzodiazepine recipients were even more likely to have certain medical diagnoses: substance abuse (OR, 7.5; 95 % CI, 5.5-10.1), alcohol abuse (OR, 3.2; 95 % CI, 2.2-4.5), tobacco use (OR, 2.7; 95 % CI, 2.1-3.5), and chronic obstructive pulmonary disease (OR, 1.5; 95 % CI, 1.2-1.9). Benzodiazepine recipients had more primary care visits per 100 patients (408 vs. 323), specialist outpatient visits (815 vs. 578), emergency department visits (47 vs. 29), and hospitalizations (26 vs. 15; p < .001 for all comparisons). CONCLUSIONS: Clinicians prescribed benzodiazepines and high-dose benzodiazepines more frequently to patients at higher risk for benzodiazepine-related adverse events. Benzodiazepine prescribing was associated with increased healthcare utilization.

The Relationship of Hypochondriasis to Anxiety, Depressive, and Somatoform Disorders.

BACKGROUND: Though the phenotype of anxiety about medical illness has long been recognized, there continues to be debate as to whether it is a distinct psychiatric disorder and, if so, to which diagnostic category it belongs. OBJECTIVE: Our objective was to investigate the pattern of psychiatric comorbidity in hypochondriasis (HC) and to assess the relationship of health anxiety to anxiety, depressive, and somatoform disorders. METHODS: Data were collected as part of a clinical trial on treatment methods for HC. In all, 194 participants meeting criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) HC were assessed by sociodemographic variables, results of structured diagnostic interviews, and validated instruments for assessing various symptom dimensions of psychopathology. RESULTS: Most of the individuals with HC had comorbid psychiatric illness; the mean number of comorbid diagnoses was 1.4, and 35.1% had HC as their only diagnosis. Participants were more likely to have only comorbid anxiety disorders than only comorbid depressive or somatoform disorders. Multiple regression analysis of continuous measures of symptoms revealed the strongest correlation of health anxiety with anxiety symptoms, and a weaker correlation with somatoform symptoms; in multiple regression analysis, there was no correlation between health anxiety and depressive symptoms. CONCLUSION: Our findings suggest that the entity of health anxiety (HC in DSM-IV and illness anxiety disorder in DSM-5) is a clinical syndrome distinct from other psychiatric disorders. Analysis of comorbidity patterns and continuous measures of symptoms suggest that its appropriate classification is with anxiety rather than somatoform or mood disorders.

Assessing the New DSM-5 Diagnosis of Somatic Symptom Disorder.

The conceptualization of somatization and what were previously termed somatoform disorders has changed substantially in the DSM-5 compared with previous diagnostic systems. The current diagnostic criteria for somatic symptom disorder (SSD) require the presence of symptoms (Criterion A) combined with a substantial impact of these symptoms on thoughts, emotions, and behaviors (Criterion B). In this issue of Psychosomatic Medicine, Toussaint et al. describe the development and empirical validation of a self-report questionnaire --the SSD-12--to assess the new psychological criteria (the "B criteria") of DSM-5 SSD. This is an important contribution because previously there was no questionnaire available to assess the B Criterion of SSD. The new DSM-5 criteria for SSD no longer require the absence of an adequate medical explanation for a somatic symptom, but rather define positive diagnostic criteria, focusing on the psychological impact of the somatic symptoms rather than their purported (medical) cause. Although this new conceptualization of somatization-related disorders has several advantages, seriously ill medical patients may well score high on the B Criterion for SSD on that basis alone and not because their psychological response to the medical illness is disproportionate or excessive. Measures of medical morbidity therefore need to be included in the interpretation of the SSD in individuals with severe medical conditions. Given the revised DSM-5 criteria, the newly developed and validated SSD-12 is a useful tool for diagnosing and monitoring treatment response in SSD.

A neural circuit framework for somatosensory amplification in somatoform disorders.

Although somatosensory amplification is theorized to serve a critical role in somatization, it remains poorly understood neurobiologically. In this perspective article, convergent visceral-somatic processing is highlighted, and neuroimaging studies in somatoform disorders are reviewed. Neural correlates of cognitive-affective amplifiers are integrated into a neurocircuit framework for somatosensory amplification. The anterior cingulate cortex, insula, amygdala, hippocampal formation, and striatum are some of the identified regions. Clinical symptomatology in a given patient or group may represent dysfunction in one or more of these neurobehavioral nodes. Somatosensory amplification may, in part, develop through stress-mediated aberrant neuroplastic changes and the neuromodulatory effects of inflammation.

Childhood Environment as a Predictor of Perceived Health Status in Late Life.

Prior studies have shown that perceived health status is a consistent and reliable predictor of morbidity and mortality. Because perceived health status and objective health are not highly correlated, we sought to identify additional factors that shape self-perceptions of health. Research suggests that childhood experience is an important predictor of health in adulthood, but most studies are retrospective. Using data from a 70-year prospective study of psychosocial development, we examined the quality of childhood environment as a predictor of perceived health in late life. This study utilizes questionnaire data from a longitudinal study of adult development to examine predictors of perceived health across seven decades. Participants were members of the Study of Adult Development, a longitudinal study of men followed for seven decades beginning in late adolescence. Childhood environment characteristics were assessed during home visits and interviews with respondents' parents at entry into the study. At ages 63, 73, and 78, current health status was measured by an internist not affiliated with the Study, and perceived health was assessed via self-report questionnaires. Linear regression analyses were conducted to examine childhood environment as a predictor of perceived health status at these 3 time points while controlling for concurrent objective health and young adult neuroticism. Childhood environment predicted perceived health at all 3 time points. This study supports the hypothesis that the quality of childhood environment makes a unique contribution above and beyond personality traits and objective health status to perceptions of health in late life.

Somatic symptom disorder: an important change in DSM.

This paper describes the rationale for the new diagnosis of somatic symptom disorder (SSD) within DSM5. SSD represents a consolidation of a number of previously listed diagnoses. It deemphasizes the centrality of medically unexplained symptoms and defines the disorder on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms. Data are presented concerning reliability, validity, and prevalence of SSD, as well as tasks for future research, education, and clinical practice.