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Abstract
Somatoforme Störungen sind gekennzeichnet durch persistierende somatische Beschwerden, die eine körperliche Störung nahelegen, ohne daß dafür eine angemessene organische Ursache (anhand organischer Befunde oder bekannter pathophysiologischer Mechanismen) nachgewiesen werden kann. Sollte eine organische Erkrankung damit in Verbindung stehen, gehen die Beschwerden bzw. die daraus resultierenden sozialen und beruflichen Beeinträchtigungen weit über das aufgrund des körperlichen Befundes erwartete Ausmaß hinaus. Da die Symptome der Somatoformen Störungen am klarsten mittels psychologischer Konstrukte faßbar sind, werden diese Störungen als Psychische Störungen klassifiziert (DSM-III-R 1987).
Thirty inpatients with somatoform disorders were examined with the structured clinical interview SCID for psychiatric lifetime diagnosis. In the present diagnoses, we found a concordance of 63% for somatoform and affective disorders and the lifetime comorbidity of both disorders was 87%. Additionally, patients with somatoform disorders frequently had a history of other psychiatric disorders (for example, anxiety disorders, 40%). For 73% of patients with somatoform disorders and a history of affective disorders, the onset of the somatoform disorder was prior to the onset of another psychiatric disorder. The time interval between the onsets of somatoform disorders and affective disorders was greater than 1 year for most patients; for 46% of the patients with a history of both disorders, the time interval between the two disorders was more than 5 years. The course of illness for somatoform and affective disorders was quite different; while affective disorders tended to episodic periods with interim remissions, the somatoform disorders usually showed long, chronic courses (mean duration of the current somatoform disorder was 11.9 years). Finally, the Symptom Check List SCL-90R demonstrated good discrimination between patients with affective and anxiety disorders. However, the SCL-90R failed to discriminate patients with somatoform disorders from affective- and anxiety-disordered subjects. Therefore, the development of other psychometric scales is necessary for the evaluation of patients with somatoform disorders.
This study examined the longitudinal course of patients known to have had a previous episode of transient hypochondriasis.
Twenty-two transiently hypochondriacal patients and 24 nonhypochondriacal patients from the same general medical clinic were reexamined after an average of 22 months with the use of self-report questionnaires, structured diagnostic interviews, and medical record review.
The hypochondriacal patients continued to manifest significantly more hypochondriacal symptoms, more somatization, and more psychopathological symptoms at follow-up. They also reported significantly more amplification of bodily sensations and more functional disability and utilized more medical care. These differences persisted after control for differences in medical morbidity and marital status. Only one hypochondriacal patient, however, had a DSM-III-R diagnosis of hypochondriasis at follow-up. Multivariate analyses revealed that the only significant predictors of hypochondriacal symptoms at follow-up were hypochondriacal symptoms and the tendency to amplify bodily sensations at the baseline evaluation.
Hypochondriacal symptoms appear to have some temporal stability: patients who experienced hypochondriacal episodes at the beginning of the study were significantly more hypochondriacal 2 years later than comparison patients. They were not, however, any more likely to develop DSM-III-R-defined hypochondriasis. Thus, hypochondriacal symptoms may be distinct from the axis I disorder. The data are also compatible with the hypothesis that preexisting amplification of bodily sensations is an important predictor of subsequent hypochondriacal symptoms.
In order to investigate the concept of hypochondriasis a questionnaire has been devised. Evidence of its validity and reliability has been presented. This has been followed by a principal component analysis. Three factors have been identified as reflecting three dimensions of hypochondriasis, viz: Bodily Pre-occupation", "Disease Phobia" and "Conviction of the Presence of Disease with Non-Response to Reassurance". These three factors are discussed in relation to the literature on hypochondriasis. Their nature lends support to those observations which have been based on clinical experience.
Thirty inpatients with multiple somatoform symptoms admitted to a psychosomatic hospital were diagnosed using the Structured Clinical Interview for DSM-III-R and questionnaires. Two years later, a reexamination by interview and a follow-up questionnaire took place. The authors found high comorbidity rates not only for affective disorders (lifetime 86%), but also for anxiety disorders (lifetime 43%). Comorbidity is of high prognostic relevance: whereas patients with only somatoform disorders at first assessment may remit until second assessment, in those patients with comorbidity with other psychiatric disorders, some somatoform symptoms still remain. The rate of misdiagnosed organic disorders is estimated at lower than 10%.
Although the two disease concepts have very different histories, many previous studies have mixed conversion disorder and somatization disorder and none has made direct comparison between them. The authors applied DSM-III criteria to inpatient and outpatient medical records and attempted to follow 98 patients who met criteria for somatization disorder or conversion disorder. Five of these patients died 4 years later and, of those who survived, 70 (75.3%) were given follow-up interviews by a rater blind to baseline diagnosis. The 32 patients with a baseline diagnosis of conversion disorder were significantly less likely than the 38 patients with somatization disorder to be given the same diagnosis at follow-up. Six of the conversion disorder patients were given follow-up diagnoses of somatization disorder and, in four other cases, subsequent developments revealed medical explanations for the presenting complaint. Of the two baseline diagnoses, somatization disorder predicted substantially more impairment in a variety of domains.
To examine the diagnostic stability and outcome of hypochondriasis, the authors followed 50 patients with this disorder and 50 age- and sex-matched control subjects after 1 year. After 1 year, two-thirds of the subjects continued to meet criteria for hypochondriasis, and the remaining third had persisting hypochondriacal symptoms. The hypochondriacal subjects were improved on most measures but still differed from the control subjects with regard to attitudes, perceptions, and behaviors that had distinguished them initially. More severe symptoms, longer duration of illness, and coexisting psychiatric illness were predictive of a worse outcome. The data indicate that the diagnosis of hypochondriasis is stable over time, and that, although symptoms wax and wane, characteristic features persist. The findings underscore the importance of diagnosing and treating hypochondriasis in medical outpatients.
In a two-year longitudinal study, a two-stage screening procedure was used to identify subjects in primary care with emotional disorder presenting with a recent onset of physical symptoms and a comparison sample of patients presenting with physical symptoms only. Somatisers (n = 44) were defined as subjects who had an emotional disorder but who presented with physical symptoms that could not be attributed to organic disease. The course and outcome of these conditions were compared with those of pure emotional disorder (n = 11), pure physical disorder (n = 90) and 'mixed' conditions (n = 39). The physical symptoms of somatisers were less likely to improve and lagged behind those of the other groups, and 16 of these acute somatisers went on to develop chronic somatoform disorders. Among somatisers, changes in physical symptom levels throughout the follow-up closely mirrored changes in emotional arousal. Emotionally disordered subjects reported more instances of parental lack of care, but somatisers were also more likely than other groups to report parental physical illness and to have had more physical illness themselves in childhood. A logistic regression suggests that adult somatisation is best modelled by parental lack of care followed by childhood illness.
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