BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

Pharmacological interventions for somatoform disorders in adults.

Objective
The purpose of this paper is to provide a comprehensive review of information accumulated over the past 26 years regarding the psychometric properties and utility of the Mini-Mental State Examination (MMSE).

Participants
The reviewed studies assessed a wide variety of subjects, ranging from cognitively intact community residents to those with severe cognitive impairment associated with various types of dementing illnesses.

Main Outcome Measures
The validity of the MMSE was compared against a variety of gold standards, including DSM-III-R and NINCDS-ADRDA criteria, clinical diagnoses, Activities of Daily Living measures, and other tests that putatively identify and measure cognitive impairment.

Results
Reliability and construct validity were judged to be satisfactory. Measures of criterion validity showed high levels of sensitivity for moderate-to-severe cognitive impairment and lower levels for mild degrees of impairment. Content analyses revealed the MMSE was highly verbal, and not all items were equally sensitive to cognitive impairment. Items measuring language were judged to be relatively easy and lacked utility for identifying mild language deficits. Overall, MMSE scores were affected by age, education, and cultural background, but not gender.

Conclusions
In general, the MMSE fulfilled its original goal of providing a brief screening test that quantitatively assesses the severity of cognitive impairment and documents cognitive changes occurring over time. The MMSE should not, by itself, be used as a diagnostic tool to identify dementia. Suggestions for the clinical use of the MMSE are made.

The mini-mental state examination: a comprehensive review.

Objective. —To assess the validity and utility of PRIME-MD (Primary Care Evaluation of Mental Disorders), a new rapid procedure for diagnosing mental disorders by primary care physicians. Design. —Survey; criterion standard. Setting. —Four primary care clinics. Subjects. —A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians. Main Outcome Measures. —PRIME-MD diagnoses, independent diagnoses made by mental health professionals, functional status measures (Short-Form General Health Survey), disability days, health care utilization, and treatment/ referral decisions. Results. —Twenty-six percent of the patients had a PRIME-MD diagnosis that met full criteria for a specific disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . The average time required of the primary care physician to complete the PRIME-MD evaluation was 8.4 minutes. There was good agreement between PRIME-MD diagnoses and those of independent mental health professionals (for the diagnosis of any PRIME-MD disorder, κ=0.71; overall accuracy rate=88%). Patients with PRIME-MD diagnoses had lower functioning, more disability days, and higher rates of health care utilization than did patients without PRIME-MD diagnoses (for all measures, P Conclusion. —PRIME-MD appears to be a useful tool for identifying mental disorders in primary care practice and research. ( JAMA . 1994;272:1749-1756)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=383992&pdfFileName=jama_272_22_029.pdf

Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care: The PRIME-MD 1000 Study

Background General population survey data are presented on the lifetime prevalence of suicide attempts as well as transition probabilities to onset of ideation, plans among ideators, and attempts among ideators either with or without a plan. Risk factors for these transitions are also studied. Methods Data are from part II of the National Comorbidity Survey, a nationally representative survey carried out from 1990 to 1992 in a sample of 5877 respondents aged 15 to 54 years to study prevalences and correlates of DSM-III-R disorders. Transitions are estimated using life-table analysis. Risk factors are examined using survival analysis. Results Of the respondents, 13.5% reported lifetime ideation, 3.9% a plan, and 4.6% an attempt. Cumulative probabilities were 34% for the transition from ideation to a plan, 72% from a plan to an attempt, and 26% from ideation to an unplanned attempt. About 90% of unplanned and 60% of planned first attempts occurred within 1 year of the onset of ideation. All significant risk factors (female, previously married, age less than 25 years, in a recent cohort, poorly educated, and having 1 or more of the DSM-III-R disorders assessed in the survey) were more strongly related to ideation than to progression from ideation to a plan or an attempt. Conclusions Prevention efforts should focus on planned attempts because of the rapid onset and unpredictability of unplanned attempts. More research is needed on the determinants of unplanned attempts.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/205075/yoa8303.pdf

Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey.

Attentional bias is a central feature of many cognitive theories of psychopathology. One of the most frequent methods of investigating such bias has been an emotional analog of the Stroop task. In this task, participants name the colors in which words are printed, and the words vary in their relevance to each theme of psychopathology. The authors review research showing that patients are often slower to name the color of a word associated with concerns relevant to their clinical condition. They address the causes and mechanisms underlying the phenomenon, focusing on J.D. Cohen, K. Dunbar, and J.L. McClelland's (1990) parallel distributed processing model.

/pdf/the-emotional-stroop-task-and-psychopathology-14bqqx5tx0.pdf

The Emotional Stroop Task and Psychopathology

• The prevalence of obsessive-compulsive disorder was measured in five US communities among more than 18500 persons in residential settings as part of the National Institute of Mental Health (Bethesda, Md)—sponsored Epidemiologic Catchment Area program. Lifetime prevalence rates ranged from 1.9% to 3.3% across the five Epidemiologic Catchment Area sites for obsessive-compulsive disorder diagnosed without DSM-III exclusions and 1.2% to 2.4% with such exclusions. These rates are about 25 to 60 times greater than had been estimated on the basis of previous studies of clinical populations.

The Epidemiology of Obsessive-Compulsive Disorder in Five US Communities

• We examined the prevalence of somatization disorder symptoms elicited with the Diagnostic Interview Schedule in 3132 community respondents interviewed in Los Angeles by the Epidemiologic Catchment Area program. The variables age, gender, ethnic background, and the presence of a psychiatric diagnosis significantly influenced the number of somatization symptoms reported. An introductory review on conceptual and nosological aspects of somatization phenomena led to the formulation of a less-restrictive operational definition of the somatizer. We found that 4.4% of the respondents met criteria for this abridged cutoff score of somatization, whereas only 0.03% of the respondents met criteria for the fullDSM-IIIsomatization disorder diagnosis. This abridged cutoff score was associated with sociodemographic factors and psychiatric diagnosis in the direction predicted.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=psych&articleId=494100&pdfFileName=archpsyc_44_8_006.pdf

Somatization in the Community

The Mini-Mental State Evaluation (MMSE) was used in an epidemiological survey of a community of mixed ethnicity (Hispanic, white non-Hispanic) as part of the Los Angeles Epidemiologic Catchment Area Program. Results of the study showed that age, educational level, ethnicity, and language of the interview influenced the number of MMSE errors. Items on which the effects of ethnicity and language were most pronounced were identified, and suggestions on ways to minimize such sociocultural artifacts are provided in efforts to improve the epidemiological significance of the instrument, particularly as it concerns cross-cultural research.

Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts.

Data were collected as a supplement to the Los Angeles Epidemiologic Catchment Area project, one of five field sites of a National Institute of Mental Health-initiated program. The authors used a two-stage probability sampling technique to interview 3,132 Los Angeles residents of two mental health catchment areas during the period January 1983-August 1984. Hispanics and non-Hispanic whites were about equally represented in the sample, as were males and females. Respondents were asked, "In your lifetime has anyone ever tried to pressure or force you to have sexual contact? By sexual contact I mean their touching your sexual parts, your touching their sexual parts, or sexual intercourse?" Persons who reported an assault were asked additional questions, including information about the most recent assault. Lifetime prevalence of sexual assault during adulthood (at or after age 16 years) was estimated at 10.5% for the entire sample. Women, non-Hispanic whites, and young people (less than age 40 years) reported higher rates of sexual assault than men, Hispanics, and older people. Highest rates were reported by young non-Hispanic white women with some college education (26.3%). In the most recent sexual assault, three-fourths of respondents knew their assailant, over half experienced harm or the threat of harm, and half experienced sexual contact including but not limited to intercourse.

Jacqueline M. Golding

Papers

The Epidemiology of Obsessive-Compulsive Disorder in Five US Communities

Somatization in the Community

Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts.

The prevalence of adult sexual assault the los angeles epidemiologic catchment area project

Long-term psychological sequelae of child sexual abuse: The Los Angeles Epidemiologic Catchment Area study.