Psychosomatics 47:143-146, March-April 2006
doi: 10.1176/appi.psy.47.2.143
© 2006 Academy of Psychosomatic Medicine
Use of the Diagnostic Criteria for Psychosomatic Research (DCPR) in a Community Sample
Lara Mangelli, Ph.D.,
Federica Semprini, Psy.D.,
Laura Sirri, Psy.D.,
Giovanni A. Fava, M.D., and
Nicoletta Sonino, M.D.
Received February 10, 2005; revised April 14, 2005; accepted May 13, 2005. From the Dept. of Psychology, Univ. of Bologna, Bologna, Italy; the Dept. of Psychiatry, State Univ. of New York, Buffalo, NY; and the Dept. of Statistical Sciences, Univ. of Padova, and Dept. of Mental Health, Padova, Italy. Send correspondence and reprint requests to Giovanni A. Fava, M.D., Dipartimento di Psicologia, Viale Berti Pichat, 5, 40127 Bologna, Italy. e-mail: giovanniandrea.fava{at}unibo.it
© 2006 The Academy of Psychosomatic Medicine
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ABSTRACT
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The authors assessed the prevalence of Diagnostic Criteria for Psychosomatic Research (DCPR) clusters in a community sample and the association between these syndromes and psychosocial variables. A group of 347 consecutive subjects from the general population were administered the semistructured interview for DCPR and a self-rating scale (the Psychosocial Index). A DCPR syndrome was identified in 59% of subjects. These subjects showed more stress and distress and less well-being than those without a DCPR syndrome. Some DCPR syndromes (alexithymia, Type A behavior, irritable mood) are frequently encountered in a community sample and are associated with impairment in quality of life. Other syndromes (demoralization, persistent somatization) that have been frequently found in medically ill persons were uncommon in this general-population sample.
Key Words: community samples • diagnostic criteria • psychosomatic research
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INTRODUCTION
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In the past few years, there has been emerging awareness about the importance of subclinical symptoms, which may have a considerable impact on quality of life and have pathophysiological and therapeutic implications.1–3 This applies particularly to the setting of physical illness, where most psychological symptoms cannot be assigned to a suitable rubric according to psychiatric diagnostic criteria.4 Alternative diagnostic and conceptual frameworks have been proposed by an international group of investigators.5 The aim of the Diagnostic Criteria for Psychosomatic Research (DCPR) was to translate psychosocial variables derived from dimensional instruments that were used in the psychosomatic literature into operational categories whereby individual patient groups could be identified.5,6
The DCPR includes 12 psychosomatic syndromes; 4 of them were conceived to provide a better specification of the DSM–IV rubric of psychological factors affecting medical conditions (i.e., alexithymia, Type A behavior, irritable mood, demoralization). The other eight diagnostic criteria were concerned with clinical phenomena related to the process of somatization and were developed as substitutes for or supplementary to the DSM categories of somatoform disorders. These new diagnostic criteria encompassed disease phobia, thanatophobia, health anxiety, illness denial, functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms, and anniversary reaction.
Recent studies showed that these syndromes were more prevalent than those identified by DSM–IV criteria in medical populations.7–11
The aim of this exploratory research was to study, for the first time, the prevalence of DCPR clusters in a community sample and the association between these syndromes and psychosocial variables (stress, psychological distress, abnormal illness behavior, and psychological well-being).
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METHOD
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Sample
The sample included 347 subjects from the general population, recruited by advertisement, in northern Italy. The respondents included 181 men (52%) and 166 women (48%), with a mean age of 37.53 (standard deviation [SD]: 12.49) years, ranging from 18 to 64 years; 148 people (43%) were married; 96 subjects (28%) had a low level of education, and 251 (72%) had 13 or more years of education.
Written informed consent was obtained from all subjects.
Assessment
All subjects were administered a semistructured interview and a self-rating questionnaire by a clinical psychologist with experience in psychosomatic research. The instruments were the following: 1) the Italian version of the semistructured interview for DCPR, related to DCPR syndromes12 (This interview has excellent interrater reliability.13) and 2) the Italian version of the Psychosocial Index (PI), a self-rated instrument comprising 55 items, for assessing acute and chronic stress, psychological distress, abnormal illness behavior, and psychological well-being.14
Statistical Analysis
Two-tailed t-tests and chi-squared tests were used to evaluate differences between groups.
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RESULTS
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A group of 142 subjects (41%) did not satisfy the criteria for any DCPR syndrome, and 205 subjects (59%) received at least one DCPR diagnosis. There were 260 syndromes identified: 195 (75%) related to psychosocial factors affecting individual vulnerability (alexithymia, Type A behavior, irritable mood, demoralization), 30 (12%) to abnormal illness behavior (disease phobia, thanatophobia, health anxiety, illness denial), and 35 (13%) related to the category of somatization disorders (functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms, anniversary reaction). Table 1 highlights the specific syndromes.
Table 2 shows the correlations between DCPR syndromes and the other variables in our sample. The presence of a DCPR cluster was negatively correlated with well-being (p<0.01), and positively correlated with psychological distress (p<0.001) and stress (p<0.05).
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TABLE 2. Differences in Sociodemographic Variables and PSI Scores Between Subjects With At Least One DCPR Syndrome and Those With No Diagnoses
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There were no significant sociodemographic differences between the two groups.
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DISCUSSION
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The data showed a high prevalence of DCPR syndromes in a community sample (59% of the subjects received at least one DCPR diagnosis). The sample was recruited by advertisements and was not a random sample representative of the general population. However, our goal was not to perform an epidemiological survey, but to study the prevalence of psychosomatic syndromes in a sample known to be probably different from people with medical disorders. Despite these limitations, the study has provided new and important clinical insights regarding the assessment of psychosomatic symptoms in a community sample. Moreover, these findings may have important implications in terms of prevention.
The presence of DCPR syndromes in the general population was associated with increased stress and psychological distress, and decreased well-being, as we found to be the case also with medical patients.11
The most representative syndromes in this sample concern the area of "psychosocial factors affecting individual vulnerability," namely Type A behavior, irritable mood, and alexithymia.
Type A behavior was the most frequent syndrome in our community sample (25%). Competitiveness and a strong sense of time-urgency may be characteristic of the current lifestyle. It would also be reasonable to investigate whether these data relate to the presence of bipolar symptoms in this population.15 Type A behavior is also highly represented in cardiology, where the percentage of patients ranges between 20% and 40%.7,9 In this setting, subjects with Type A behavior seem to present a behavioral pattern characterized by hostility and a sense of being under time pressure.16
In this community sample, alexithymia was also highly represented (15%). This percentage is in accordance with the data found with the TAS-2017–20 in the literature on adults (8%–19%). Alexithymia represents a trait of personality that may have serious implications once a medical illness arises. In fact, despite the fact that alexithymia continues to be a controversial concept, particularly in its assessment, it seems that the inhibition of emotional expression and, particularly, a life-long tendency to suppress anger, have been found to involve an increased risk for a variety of health problems.21,22 Irritable mood is characterized by brief or prolonged and generalized episodes of negative mood, often associated with uncontrollable verbal or behavioral outbursts and unpleasant sensations.5 Irritable mood is highly represented in our sample (13%). This result agrees with those found in medical populations, where the proportion of irritable mood ranges between 10% and 18%.7–11
Other pertinent findings are a low prevalence of demoralization and persistent somatization in the community sample.
A substantial problem of research in demoralization lies in the various ways in which it is defined, ranging from general distress23 to a specific syndrome characterized by subjective incompetence.24 DCPR criteria outlines a definition of demoralization based on the phenomenological description of the Rochester Group (the "giving-up" complex).25 Demoralization is characterized by feelings of helplessness, hopelessness, or giving up; the state of feeling is prolonged and generalized, and closely antedates the manifestation of the medical disorder or exacerbation of its symptoms.5 Mangelli et al.26 showed how the DCPR detected the presence of demoralization in 30% of medical patients, suggesting that this syndrome is frequent across different medical settings. In our sample, the same interview identified only 3% of subjects as suffering from demoralization. This points to the fact that DCPR criteria for demoralization may be related to the onset of medical disturbances and do not simply identify generic psychological distress.
The presence of persistent somatization is in line with the results for demoralization. Persistent somatization is characterized by functional medical disorder whose duration exceeds 6 months, causing distress or repeated medical intervention or resulting in impaired quality of life.5 There is a high frequency of this disorder in specific medical settings, such as gastroenterology (29.5%),8 compared with the very low percentage of this syndrome in our community sample (2%). Again, these results suggest that the DCPR criteria identify a syndrome worthy of clinical attention.
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REFERENCES
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G. A. Fava, S. Fabbri, L. Sirri, and T. N. Wise
Psychological Factors Affecting Medical Condition: A New Proposal for DSM-V
Psychosomatics,
April 1, 2007;
48(2):
103 - 111.
[Abstract]
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ABSTRACT
INTRODUCTION
