Journal Article Annotations
2020, 4th Quarter

Somatic symptom disorders

Annotations by Mary Burke, MD, Luis Pereira, MD
December, 2020

Pacella-LaBarbara, M et al., “Event centrality following treatment for physical injury in the emergency department: Associations with posttraumatic outcomes.
Suicide and suicidality in somatic symptom and related disorders: A systematic review

PUBLICATION #1 — Somatic symptom disorders

Pacella-LaBarbara, M et al., “Event centrality following treatment for physical injury in the emergency department: Associations with posttraumatic outcomes.

Maria Pacella-LaBarbara, Sadie E Larsen, Stephany Jaramillo, Brian Suffoletto, Clifton Callaway

Abstract: Gen Hosp Psychiatry. Nov-Dec 2020;67:77-82. doi: 10.1016/j.genhosppsych.2020.09.002. Epub 2020 Sep 30.

Background:
The relationship between event centrality (i.e., the degree to which a stressful event is integrated into one’s identity) and acute posttraumatic outcomes after relatively minor physical injury is unknown. We examined pre-injury and Emergency Department (ED) predictors of event centrality at 6-weeks post-injury, and whether event centrality is uniquely associated with 6-week posttraumatic outcomes.

Methods:
In the EDs of two Level I trauma centers, 149 patients completed surveys regarding demographic, psychological and injury-related factors within 24 h post injury; 84 patients (51% male) completed 6-week surveys of event centrality, posttraumatic stress symptoms (PTSS) and trauma-specific QOL (T-QoL). Data were analyzed using linear regression modeling.

Results:
At least 20% of patients agreed or strongly agreed that the injury changed their life. Hospitalization status and peritraumatic dissociation were significant predictors of event centrality at 6-weeks. After controlling for demographics, ED-related factors and pre-injury PTSS, event centrality was uniquely associated with PTSS (p < .001) and T-QOL (p < .001) at 6 weeks.

Conclusion:
Over and above the effects of the injury itself, event centrality conveyed important information for posttraumatic outcomes at 6 weeks post-injury. The centrality scale is brief and feasible to administer; future work is needed to determine the predictive utility of event centrality on post-injury outcomes.

Annotation

The finding:
While not directly addressing SSD, the study investigates how contextual and psychological factors predict negative outcomes after non-life-threatening injury. The results state that “event centrality”—an individual’s experience of an accident as life-changing—predicts more negative outcomes, as measured by post-traumatic (PT) symptoms and quality of life measures. Event centrality itself was associated with hospitalization (only medically stable patients with hospitalizations </= 24 h were enrolled); and peri-accident dissociation. PT symptoms and reduced quality of life were not associated with injury severity or pain in the ED.

Strength and weaknesses:
The study was a prospective study of patients recruited in the ED. It is one of a number of studies trying to tease out psychological contributions to morbidity after relatively minor injury. Weaknesses include small sample size and limitations in recruitment hours (during workdays versus nights and weekends, when ED’s are often busiest.) Study subjects were victims of accidental, not interpersonal injury—the latter have been known to experience deeper psychological impact. More men than women were in the original samples; a higher percentage of women completed the study although the number of men and women completing were almost equal. The authors note difficulty in generalizing to more severely injured groups. Follow-up was limited to six weeks. However, even with these limitations the study indicates the discrepancy between initial physical injury severity and pain and ensuing psychological injury.

Relevance:
The concept of “event centrality” is another lens for understanding the discrepancy between “objective” physical findings and later morbidity and reduced quality of life. The authors suggest that early psychological interventions that provide coping strategies (versus reliving the trauma) may improve longer-term outcomes.

Type of study: (EBM guide):
Cohort study

PUBLICATION #2 — Somatic symptom disorders

Suicide and suicidality in somatic symptom and related disorders: A systematic review

Michael E Torres, Bernd Löwe, Samantha Schmitz, John N Pienta, Christina Van Der Feltz-Cornelis, Jess G Fiedorowicz

Abstract: J Psychosom Res. 2021 Jan;140:110290. doi: 10.1016/j.jpsychores.2020.110290. Epub 2020 Nov 10.

Objective
We sought to determine the frequency of and risk factors for suicide outcomes in somatic symptom and related disorders and whether any risk was independent of co-occurring mental disorders.

Methods
We conducted a systematic review of studies on suicide death, suicide attempts, and suicidal ideation in those with somatic symptom disorders published prior to September 22, 2020 and indexed in PubMED, MEDLINE, PsycARTICLES, PsycINFO, EMBASE, or SCOPUS according to PRISMA guidelines.

Results
Our search yielded 33 articles with significant heterogeneity in study design, sample selection, and assessment for suicide or risk factors. While suicide deaths have not been adequately studied, somatic symptom and related disorders are associated with increased risk for suicidal ideation and suicide attempts, with estimates ranging from 24 to 34% of participants who endorsed current active suicidal ideation and 13–67% of participants who endorsed a prior suicide attempt. The risk appeared independent of co-occurring mental disorders. Identified risk factors for suicide attempts in samples with somatic symptom and related disorders include scores on measures of anger, alexithymia, alcohol use, past hospitalizations, dissociation, and emotional abuse.

Conclusion
Although the literature is sparse, there exists evidence for an association, even independent of other mental disorders, between somatic symptom and related disorders and suicide outcomes. Practice guidelines for the management of these disorders should incorporate recommendations for the assessment and management of suicide risk. Future study is necessary to more fully elucidate potential unique risk factors for those suffering from these complex disorders.

Annotation

The finding:
The study exhaustively reviews literature to date on the relationship between somatic symptom disorders (SSDs) and suicide risk. While hypochondriasis/ illness anxiety disorder is not associated with suicidality, other SSD’s including pain disorders and functional disorders do confer risk; those with comorbid anxiety or mood disorders are at higher risk than those without SSDs.

Strength and weaknesses:
This paper describes a comprehensive review of the literature using six databases and PRISMA reporting guidelines. Search strategies included international papers published in English, and findings were relatively consistent across cultures. Because of the variability of diagnostic terminology and the evolution of concepts of somatic symptom disorders over time, comparing studies or making a synthesis is difficult.

Relevance:
SSDs tend to be dismissed as “hysteria” in the medical world; in fact they represent a real mental health risk. C-L psychiatrists can educate colleagues on the importance of screening for suicidal ideation and past attempts in this group of patients—the authors note that this recommendation is absent from many guidelines for treating SSDs. In addition, this review suggests that illness anxiety is categorically different from other somatic symptom disorders, which appear to be a more serious mental health condition.

Type of study: (EBM guide):
Systematic review or meta-analysis