Transdiagnostic Processes as Mediators of Change in an Internet-Delivered Intervention Based on the Unified Protocol

Background Transdiagnostic treatments target shared mechanisms between disorders to facilitate change across diagnoses. The Unified Protocol (UP) aims at changing dysfunctional reactions towards emotions by increasing mindful emotion awareness and cognitive flexibility, as well as decreasing anxiety sensitivity and emotion avoidance. Method We investigated whether these transdiagnostic processes were malleable by treatment and mediated the relationship between treatment and outcome in an internet-delivered adaptation of the UP. N = 129 participants with mixed anxiety, depressive, and somatic symptom disorders were randomized to treatment or waitlist. Results The treatment yielded significant changes in all transdiagnostic processes over time in comparison to a waitlist condition. In separate mediator models, significant mediating effects were found for mindfulness, cognitive flexibility, behavioral activation, and experiential avoidance. When all mediators were combined in a multiple mediator model, the indirect effects through mindfulness and cognitive flexibility emerged as significant. Conclusion These findings add to the growing body of research on transdiagnostic processes as mediators of change and emphasize mindfulness and cognitive flexibility as a transdiagnostic treatment target. However, these results should be interpreted cautiously, as temporal precedence could not be established.

The factitious/malingering continuum and its burden on public health costs: a review and experience in an Italian neurology setting

Factitious disorder is classified as one of the five aspects of somatic symptom disorders. The fundamental element of factitious disorder is deception, i.e., pretending to have a medical or psychiatric disorder, but the enactment of deception is considered unconscious. Indeed, volition, i.e., the perception of deliberate deception, is blurred in patients presenting with factitious disorder. In the USA and the UK, factitious disorder has received constant media attention because of its forensic implications and outrageous costs for the National Health Systems. Unfortunately, a comparable level of attention is not present in Italian National Health System or the Italian mass media. The review analyzes the classifications, disorder mechanisms, costs, and medico-legal implications in the hope of raising awareness on this disturbing issue. Moreover, the review depicts 13 exemplification cases, anonymized and fictionalized by expert writers. Finally, our paper also evaluates the National Health System’s expenditures for each patient, outlandish costs in the range between 50,000 and 1 million euros.

Somatic symptom disorders and utilization of health services among Palestinian primary health care attendees: a cross-sectional study

Background Many primary health care (PHC) clients come in with medically unexplained complaints, leading to frequent consultations and high usage of services and healthcare costs. This study aimed to determine the prevalence of somatic symptom disorder (SSD) among PHC attendees and explore its relation to other mental conditions and risk factors. Methods A cross-sectional design was used to interview 400 attendees. Men and women aged over 18 years old without a psychiatric diagnosis were invited to participate. The Somatization scale of the Four-Dimensional Symptom Questionnaire was used to assess somatic symptom disorders. It is a valid tool to be used in a PHC setting. We used the Chi-square test and multivariable logistic regression to explore determinant variables. Results Prevalence of SSD was 32.5% (95%CI = 27.9–37.1%). The most common symptoms were painful muscles (61.5%) followed by back pain (52.3%). Female gender [adjusted OR = 2.1 (95% CI = 1.2–3.7)], chronic diseases [adjusted OR = 2.4 (95%CI = 1.3–4.5)], depression [adjusted OR = 3.3 (95%CI = 2.0–5.5)], and anxiety [adjusted OR = 2.1 (95%CI = 1.2–3.6)] were all associated with SSD. In addition, frequent primary health care attendance was found to be associated with SSD [adjusted OR = 2.4 (95%CI = 1.4–4.1)]. Conclusions SSD significantly higher among females, patients with chronic diseases, clients with anxiety and depressive disorders, and patients with frequent doctors’ visits. Painful muscles and back pain are the most common symptom presented by patients, and this could be used initially by PHC physicians as a signal to consider for screening.

FACTORS CONTRIBUTING TO WELL-BEING: COMPARING FUNCTIONAL SOMATIC SYMPTOM DISORDERS AND WELL-DEFINED AUTOIMMUNE DISORDERS

"Functional somatic symptom disorders (FSSDs) are defined by persistent and chronic bodily complaints without a pathological explanation. Mindfulness involves the focus on the present moment by noticing surroundings, thoughts, feelings, and events, being nonreactive, being non-judgemental, and self-accepting. Psychological flexibility (PF) involves a focus on the present and the prioritization of thoughts, emotions, and behaviours that align with individual values and goals (Francis et al., 2016). Although PF does not involve a mindfulness practice, the two constructs are related. Research indicates consistent reported positive associations between mindfulness, PF, psychological wellbeing, and medical symptoms. In this study, individuals with FSSDs (fibromyalgia, chronic fatigue syndrome) were compared to those with well-defined autoimmune illnesses (multiple sclerosis, rheumatoid arthritis; AD) to determine how psychosocial factors affect wellness. Participants (N = 609) were recruited from social media and online support groups and completed questionnaires to assess physical health (Chang et al., 2006), psychological wellness (Diener et al., 1985), anxiety (Spitzer et al., 2006), depression (Martin et al., 2006), psychological flexibility, (Francis et al., 2016) and mindfulness (Droutman et al., 2018]. Results indicated that having an FSSD and higher depression was associated with both lower physical and psychological wellness. Interestingly, different aspects of psychological flexibility predicted physical and psychological wellness. These results suggest that different aspects of PF are associated with better physical and psychological health. As PF is modifiable, individuals with chronic conditions could receive training that could ultimately improve their overall health."

Transdiagnostic Processes as Mediators of Change in an Internet-delivered Intervention based on the Unified Protocol

Background: Transdiagnostic treatments target shared mechanisms between disorders to facilitate change across diagnoses. The Unified Protocol (UP) aims at changing dysfunctional reactions towards emotions by increasing mindful emotion awareness and cognitive flexibility, as well as decreasing anxiety sensitivity and emotion avoidance. Method: We investigated whether these transdiagnostic processes were malleable by treatment and mediated the relationship between treatment and outcome in an internet-delivered adaptation of the UP. N=129 participants with mixed anxiety, depressive, and somatic symptom disorders were randomized to treatment or waitlist. Results: The treatment yielded significant changes in all transdiagnostic processes over time in comparison to a waitlist condition. In single mediator models, significant mediating effects were found for mindfulness, cognitive flexibility, behavioral activation, and experiential avoidance. When all mediators were combined in a multiple mediator model, only mindfulness emerged as a significant mediator. Conclusion: These findings add to the growing body of research on transdiagnostic processes as mediators of change and emphasize mindfulness as a transdiagnostic treatment target. However, these results should be interpreted cautiously, as temporal precedence could not be established.