Psychosomatics 46:340-344, August 2005
© 2005 The Academy of Psychosomatic Medicine
Does Somatosensory Amplification Decrease With Antidepressant Treatment?
Kemal Sayar, M.D.,
Arthur J. Barsky, M.D., and
Huseyin Gulec, M.D.
Received Nov. 13, 2003; revision received Sept. 17, 2004; accepted Oct. 28, 2004. From the Bakirkoy Mental Health Training and Research Hospital, Istanbul, Turkey; and the Department of Psychiatry, Harvard Medical School, Boston. Address correspondence and reprint requests to Dr. Sayar, Inonu caddesi Sumko Sitesi, K 2 Blok D:11, Kozyatagi 81090, Istanbul, Turkey; kemalsayar{at}hotmail.com (e-mail).
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ABSTRACT
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Somatosensory amplification refers to a tendency to experience somatic and visceral sensations as unusually intense, noxious, and disturbing. The authors wanted to determine whether somatosensory amplification is a stable construct or whether it might change with antidepressant therapy. Fifteen patients with fibromyalgia and 17 patients with major depressive disorder received antidepressant treatment and were assessed after 6 and 12 weeks of treatment. Amplification scores responded to antidepressant treatment in patients with major depression but not in patients with fibromyalgia, despite a decrease in the levels of depression in both groups. When change in depression and anxiety scores was partialled out from change in somatosensory amplification scores, the amplification scores did not change significantly in either the depressed or the fibromyalgia groups. Given the small numbers and the marginal significance of the results, the authors are unable to say definitely just how independent of depression somatosensory amplification is. Whether somatosensory amplification is a measure of depression per se should be tested in a more definitive and larger future study.
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INTRODUCTION
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Somatosensory amplification refers to the tendency of experiencing somatic and visceral sensations as unusually intense, noxious, and disturbing. It involves bodily hypervigilance, the predisposition to focus on certain weak and infrequent bodily sensations, and a tendency to appraise them as pathological and symptomatic of disease, rather than normalizing them.1 Alhough originally intended to account for the symptom reporting of hypochondriacal patients,2 the amplification of benign bodily sensations may be related to more general processes of somatic symptom reporting and health appraisal.3,4 The Somatosensory Amplification Scale is a self-report questionnaire developed to assess amplification. It remains unclear to what extent this scale captures an underlying mediating process of symptom amplification. In two studies with university students, Aronson and colleagues5 found that the Somatosensory Amplification Scale correlated with measures of symptom reporting and with several indices of general distress, including anxious and depressive symptoms and negative emotionality. The authors concluded that the Somatosensory Amplification Scale is more likely an index of negative emotionality and general distress than a valid measure of somatic sensitivity. On the contrary, in a study of psychiatric outpatients, Somatosensory Amplification Scale scores were significantly associated with SCL-90 somatization scores independent of gender, presence of physical disorder, and level of anxiety and depression.6 In a similar vein, Sayar et al.7 suggested that somatosensory amplification as measured by the Somatosensory Amplification Scale predicts somatic symptom reporting independent of anxiety, depression, and even alexithymia in depressed outpatients.
A recent study that employed the Somatosensory Amplification Scale in psychosomatic outpatients in Japan revealed an association between difficulties identifying and describing feelings, but not externally oriented thinking, and somatosensory amplification.8 Another study from India compared somatoform disorder patients, patients with depression, and normal subjects.9 Somatoform disorder patients had higher mean amplification scores than depressed patients, who in turn had higher scores than the normal subjects. Barsky et al.10 showed that symptoms of rheumatoid arthritis and the side effects of rheumatoid arthritis pharmacotherapy are prospectively predicted by somatic style.
To our knowledge, no prospective study has been conducted to assess the stability of the somatosensory amplification construct. If the Somatosensory Amplification Scale measures general distress, then one might hypothesize that with the treatment of these conditions, there should be a decrease in Somatosensory Amplification Scale scores. It is known that depressed individuals’ negative and pessimistic cognitive schemas foster the recall of illness-related memories, promote a negative view of their health and their future prognosis, and result in heightened awareness of unpleasant experiences.2 So if we were to treat depression or diminish its symptoms, would there also be a change in the Somatosensory Amplification Scale scores? We wanted to determine whether amplification is a stable construct or whether it might change with antidepressant therapy. We hypothesized that 1) Somatosensory Amplification Scale scores would decrease with antidepressant treatment and 2) that this decrease would parallel the decrease in depression and anxiety scores.
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METHOD
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Subjects
The study was conducted at the outpatient clinics of Karadeniz Technical University Medical School, a university hospital based in the city of Trabzon in northeastern Turkey. Two groups of subjects were recruited for the study: patients with fibromyalgia and patients with major depressive disorder. The fibromyalgia group was originally recruited to study the efficacy of the antidepressant drug venlafaxine in alleviating pain and disability, and this study has been published elsewhere.
All consecutive patients in the outpatient clinics of the physical therapy and rehabilitation departments diagnosed with fibromyalgia according to American College of Rheumatology criteria11 between December 2001 and April 2002 were interviewed. Patients with current suicidal thoughts, severe heart disease (congestive heart failure or coronary heart disease), or a debilitating neurological condition were excluded from the study as well as patients who had used psychotropic agents (antidepressants, anxiolytics, antipsychotics) or analgesics (including nonsteroidal antiinflammatory drugs) within the last month. Eighteen subjects were excluded from the study, and 20 subjects were found to be eligible. All patients provided informed consent, and none refused to participate. All the eligible patients were women. During the course of the therapy five patients left the study because of side effects of medication, leaving 15 patients who completed the study.
Patients with DSM-IV major depressive disorder according to the Structured Clinical Interview for DSM-IV Axis I Disorders12,13 were recruited from the outpatient psychiatry clinics of Karadeniz Technical University Medical School. This group consisted of consecutive patients attending the outpatient psychiatry clinics between January 2003 and March 2003. The patients were either new referrals or had recurrent episodes of a depressive disorder. Exclusion criteria were a comorbid psychotic disorder diagnosis, depression with psychotic features, cognitive decline suggestive of a true dementia, psychotropic drug use in the last 2 weeks, or a major physical health problem. The first 21 patients meeting the inclusion criteria were included in the study. None of the subjects refused to participate in the study. Nine subjects were excluded. After giving informed consent, the patients initiated antidepressant treatment. Four patients dropped out of treatment because of side effects.
Procedure
The procedures followed were in accordance with the ethical standards of Karadeniz Technical University Medical School and with the Helsinki, Finland, declaration of 1975, as revised in 1983. All subjects were assessed with the Somatosensory Amplification Scale as well as the Beck Depression Inventory15,16 and the Beck Anxiety Inventory.16,17 All patients were able to complete the questionnaires independently. The fibromyalgia patients were given a fixed dose of venlafaxine, 75 mg/day, after the initial assessment, and antidepressant and anxiolytic efficacy was assessed after 6 and 12 weeks of treatment. No change was made in the dose of the medication from the beginning to the end of the study. Patients with major depressive disorder were started on a regimen of sertraline, 50–100 mg/day in a flexible-dose pattern, and antidepressant and anxiolytic efficacy was assessed after 6 and 12 weeks of treatment. Week 12 was the primary endpoint. Patients were not given any medications other than venlafaxine or sertraline. Only data from patients who continued taking their assigned medication throughout the study are presented here.
Measures
Sociodemographic characteristics of subjects were recorded with a structured data form. The Beck Depression Inventory is a 21-item self-report questionnaire that assesses severity of depression.14 Individuals are asked to rate themselves on each item on a 0–3 scale (0=least, 3=most; score range=0 to 63). The total score is a sum of all items. It has been shown to be valid and reliable in Turkish.15 The Beck Anxiety Inventory is a 21-item self-report questionnaire.16 Each item is rated on a 4-point Likert scale (0=not at all, 3=severely, I could barely stand it; score range=0 to 63). It has been shown to be valid and reliable in Turkish.17 The Somatosensory Amplification Scale is a 10-item self-report questionnaire tapping the tendency to experience ordinary bodily and visceral sensation as intense, noxious, and disturbing.1 The respondent rates the degree to which each statement is "characteristic of you in general," on an ordinal scale from 1 to 5 (1="not at all"; 5="extremely").1 Higher scores on the Somatosensory Amplification Scale were found in hypochondriacal patients as well as in patients making frequent use of medical care.3 The Turkish translation of the Somatosensory Amplification Scale has a very good internal reliability.18
Statistical Analysis
Repeated measure analysis of variance (ANOVA) was used to compare the measures before and after treatment. Bonferroni method was used to detect which groups showed a significant difference. Pearson correlation analysis was used to examine the association between the change in Somatosensory Amplification Scale scores (if there was any change) and the change in depression and anxiety scores. Whether these relations were statistically significant was investigated with two different correlation analyses for every possible pair of variables. The significance level was set at p<0.05.
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RESULTS
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We performed a completers analysis and an intent-to-treat analysis using the last observation carried forward. The results were similar, so we present the completers analysis here. In the fibromyalgia group, 15 of 20 patients completed the study. All were women. Fourteeen were married, and one was single. Five had graduated from primary school, four from secondary school, four from high school, and two were university graduates. Two reported a history of antidepressant use. Their mean age was 37.7 years (SD=7.8). Of these 15 women, nine had no current psychiatric disorder, five patients had generalized anxiety disorder, and one had obsessive-compulsive disorder. Of the nine patients with no current psychiatric disorder, three had a history of major depressive disorder.
In the fibromyalgia group, Beck Anxiety Inventory scores decreased significantly from baseline to the sixth week of treatment and decreased further at the 12-week follow-up evaluation. Anxiety levels per the Beck Anxiety Inventory dropped steadily with treatment (F=17.6, p=0.0001). The Beck Depression Inventory scores did not show a significant decrease at week 6 but decreased significantly from baseline by week 12. There was a significant decrease of Beck Depression Inventory scores from week 6 to 12 (F=8.6, p=0.002). There was no significant difference in Somatosensory Amplification Scores throughout the treatment period (Table 1).
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TABLE 1. Change in Depression, Anxiety, and Somatosensory Amplification Symptoms During 12 Weeks of Antidepressant Treatment in Patients With Fibromyalgia (N=15) or Major Depressive Disorder (N=17)
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In the depression group, 17 out of 21 patients with major depressive disorder completed the study. Seven were women, and 10 were men. Fourteen were single, and three were married. Eleven were university students, three were unemployed, two were housewives, and two were workers. Two had a history of suicide attempts, and seven had a psychiatric history. Mean age was 24 years (SD=6.1). In this particular group of patients with major depressive disorder, antidepressant treatment caused a steady and significant decline in Beck Anxiety Inventory (F=36.78, p=0.0001) and Beck Depression Inventory (F=48.83, p=0.0001) scores. There was a significant difference between baseline, week 6, and week 12 measures in depression and anxiety scores. There was a significant difference in the Somatosensory Amplification Scale scores between baseline and the end of treatment (F=12.6, p=0.0001). The Somatosensory Amplification Scale scores decreased significantly from baseline to week 6 and week 12, but there was not a significant change between week 6 and week 12 (Table 1). The change in Somatosensory Amplification Scale scores was not correlated with the change in depression and anxiety scores in the major depressive disorder group (Table 2). Between the 6th and 12th weeks of treatment in the fibromyalgia group, there was a significant correlation between changes in the Beck Depression Inventory scores and changes in the Somatosensory Amplification Scale scores (Table 2). When changes in Beck Depression Inventory and Beck Anxiety Inventory scores were partialled out from the change in the Somatosensory Amplification Scale scores (residual SSAS) and the ANOVA rerun, the Somatosensory Amplification Scale scores did not change significantly either in the depressed (F=3.08, p=0.06) or in the fibromyalgia group (F=0.42, p=0.66), although the change in the Somatosensory Amplification Scale scores of depressed patients approached significance.
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TABLE 2. Relationship Between Change in Somatosensory Amplification and Change in Anxiety and Depression Measures During 12 Weeks of Antidepressant Treatment in Patients With Fibromylagia (N=15) or Major Depresive Disorder (N=17)
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DISCUSSION
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In this study, Somatosensory Amplification Scale scores responded to antidepressant treatment in patients with major depression but not in patients with fibromyalgia. Yet the antidepressant treatment significantly reduced the level of depression in both groups. Thus, in patients with fibromyalgia, somatosensory amplification and depression do not appear to bear a direct, one-to-one association. Somatosensory amplification appears to have a more enduring relationship with fibromyalgia such that depression can be relieved without reducing somatosensory amplification. This is in accord with much of the current thinking about this poorly understood condition, which stresses an unusually high level of somatic awareness and a reduced threshold and tolerance for pain as integral features of the disorder.
In contrast, in the depressed group, Somatosensory Amplification Scale scores declined significantly along with depression scores. This suggests that in this group, amplification may be more closely related to depression such that treatment of the former with antidepressants reduces the latter. Some uncertainty remains, however. The decline in the Beck Depression Inventory and Somatosensory Amplification Scale scores after 6 weeks and 12 weeks had correlations of 0.39 and 0.48, respectively. Although not significant, the magnitudes are great enough to suggest that their association might actually be statistically significant if more subjects were studied. Furthermore, when compared with the reductions in anxiety, these associations between the Somatosensory Amplification Scale and Beck Depression Inventory scores are much greater than those between the Somatosensory Amplification Scale and Beck Anxiety Inventory. This also suggests that the relationship between amplification and depression may ultimately be found to be considerable. However after the change in the Beck Depression Inventory and Beck Anxiety Inventory scores were partialled out from the change in Somatosensory Amplification Scale scores, the Somatosensory Amplification Scale scores did not change significantly in the depressed group, albeit the difference approached significance. Although this finding points toward an independence of the somatosensory amplification construct from depression, it must be interpreted cautiously given the marginal significance of the results.
The study has a number of limitations. First, the study groups were quite small. Second, no conclusions about the efficacy of antidepressants in these two populations can be drawn because there was no placebo arm. To some extent, the comparison between these two groups is confounded by the use of two different drugs. There would be more confidence in the results if both groups had been treated with the same drug. One should also bear in mind that the drug treatment was open-label. In addition, the antidepressant efficacy in the fibromyalgia group was limited because the venlafaxine dose was relatively low and was not increased if indicated. Indeed, it is quite surprising that in this difficult to treat group, Beck scores at the 12-week follow-up point were significantly reduced, having declined from 17 to 10.5. Third, almost half (18/38) of the fibromyalgia patients were excluded, and this raises the possibility of sampling bias.
Nontheless, this study suggests that somatosensory amplification plays a relatively independent role in fibromyalgia and perhaps a different and closer role in major depression. Further work is necessary to discern these complex interrelationships in psychiatric disorders characterized by prominent somatic symptoms (including anxiety disorders as well as depression) and in functional syndromes that include prominent pain symptoms (such as repetitive strain injury and irritable bowel syndrome, as well as fibromyalgia). Given the small numbers and the marginal significance of the results, we are unable to say definitely just how independent of depression somatosensory amplification is. Whether somatosensory amplification is a measure of depression per se should be tested in a more definitive and larger future study.
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ABSTRACT
INTRODUCTION
