Impact of symptom focusing and somatosensory amplification on persistent physical symptoms: A three-year follow-up study, 2020, Barends et al

Andy

Andy

Retired committee member
Objective
The somatosensory amplification theory considers symptom focusing and somatosensory amplification as important perpetuating factors of persistent physical symptoms. We investigated whether symptom focusing and somatosensory amplification were associated with symptom severity and mental and physical functioning over a three-year period in patients with persistent physical symptoms (PPS).

Methods
Baseline, 6-, 12-, 24- and 36-months follow-up data from the PROSPECTS study, a prospective cohort consisting of 325 patients with PPS, were used. We applied longitudinal mixed model analyses to investigate if symptom focusing (CBRQ Symptom Focusing Subscale) and somatosensory amplification (Somatosensory Amplification Scale) at baseline were associated with symptom severity (PHQ-15), mental and physical functioning (RAND-36 MCS and PCS) over three years, using all measurements.

Results
Symptom focusing was associated with increased symptom severity and lower mental and physical functioning over time. Somatosensory amplification at baseline was associated with increased symptom severity and lower mental and physical functioning over time. Effect sizes were small. Associations with baseline symptom focusing decreased over time, associations with baseline somatosensory amplification were more stable. There was no interaction effect of both constructs, but they partly overlapped.

Conclusion
This is the first study to show that over an extended period, symptom focusing and somatosensory amplification are associated with symptom severity and lower mental and physical functioning in patients with PPS. These results support the impact of both symptom focusing and somatosensory amplification on the perpetuation of symptoms and lowered mental and physical functioning in individuals with PPS.
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Paywall, https://www.sciencedirect.com/science/article/abs/pii/S0022399919306300
Sci hub, https://sci-hub.tw/10.1016/j.jpsychores.2020.110131
 
I think I'd also like to add a little anecdote to illustrate symptom focussing and symptom severity issues.

I have had tinnitus for 50+ years. In the early years I at first didn't realise that I had tinnitus all the time. Without me doing anything consciously my brain adapted. I did one day realise that if I paid attention (and then I did this several times over time) the tinnitus was always there but I was not attending to it.

Now decades later my tinnitus is quite a bit louder and harder to not attend to. It is more distressing in that outside ambient sounds are more difficult to cope with because of all this noise emanating (if that's the word) from my head.

Nevertheless I don't go through my day attending to the noise in my head more. I carry on quite as usual -- after all -- I've had 50+ years of practice in not attending to the sound. So I do not attend to it any more then I ever did. It is just that it is more intrusive and presents more difficulties in that it is particularly noticeable when trying to fall asleep (as it's dark and quiet).

I occasionally find myself pressed to speak inside the lines (rules) but these people are full on idiots* with their armchair musings on other peoples suffering.

* credit where credit is due -- I'm being nice here.
 
The somatosensory amplification theory considers symptom focusing and somatosensory amplification as important perpetuating factors of persistent physical symptoms.
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The theory is intuitively wrong, even at its most, and there are no empirical hints either.

A possible explanation:

Any living being wants success. This should even be even the definition of an intention. And the success is wanted for itself.

Pain diminishes the intention, or even better, is the diminishing of intention. Any being or intention will avoid anything which is painful.

Human beings differ to other beings in that they have quite a big thematic self reference (with its special successes). But still pain will diminish intention, and if there is no other success, it will not happen that pain is choosen (as it is not choosen by animals that have no additional thematic self reference). So, where is the success?
 
Ridiculous. There is no way to measure focus in any meaningful way and obviously stronger symptoms are more noticeable. Good grief this is so juvenile in its incompetence how these people are even allowed to work on important matters is beyond reason.

One of the most fundamental problems in science is being able to tell whether something is a cause or an effect. When you explicitly and deliberately fail at this you simply prove you don't have the skills necessary to work in science.
using all measurements
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Not a single measurement in sight, only bad questionnaire scoring. Words have meaning. This is pathetic.
 
They are trying to explain why some people have persistent physical symptoms that can't be explained by medicine.

Elevated attention focusing is assumed to turn bodily sensations into symptoms.
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There's more but text can't be copied properly so I'm not going to copy all the important parts here.

Anyway I find this idea very questionable. There is a limit to how much you can increase your own perception of symptoms, and it's an active process meaning you have to essentially work hard to make it happen. And patients learn quickly to try and distrac themselves from pain instead of "cultivating" it. As explanation it doesn't seem to fit intense and persistent symptoms, where this idea is applied because these are so frustrating.

Personal opinion aside, the effect that the authors have found is quite small (Cohen's d of 0.10).
 
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They are doing what studies of FND have done. They assume that their theory is right when they misdiagnose people, then years later they make the same misdiagnosis.

Somehow, they think that this proves they were right all along :banghead::banghead::banghead:

If I decide epilepsy is caused by demons then test the same people after 10 years, if they still have epilepsy I will again believe this means they have demons. This DOES NOT MEAN demons are involved.
 
It's pretty clear that the authors have never developed a tooth infection requiring root canal on a Friday evening after their dentist has left for the weekend. By Sunday, I can assure that their views on symptom focusing would be better informed and they'd be seeking an emergency appointment.
 
strategist said:
Personal opinion aside, the effect that the authors have found is quite small (Cohen's d of 0.10).
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Yes, I guess one could say minuscule. The Cohen d they report are all below 0.32. That would already suggest that these aren't the key factors in determining the persistent physical symptoms of these patients.

It also seems that the authors didn't correct for baseline symptom severity? I think they only controlled for age, gender, education level and somatic diseases (number of self-reported somatic diseases at baseline). I suspect there wouldn't be much left of their results if they controlled for symptom severity.
 
There are some other interesting things in this paper. It explains that 40 years ago a guy called Arthur Barsky invented the 'somatosensory amplification theory' "by describing the proneness to focus on and amplify bodily sensations and symptoms as an explanation for individual differences in experienced physical symptoms."

Normally researchers mention and discuss similar research in the opening paragraph of their paper as a sort of background to their study. Here the authors write:
We are aware of only a few longitudinal studies looking at somatosensory amplification as a predisposing factor of subjective symptoms and these yielded inconclusive results [12–14]. To the best of our knowledge, there are no longitudinal studies investigating the role of somatosensory amplification as a perpetuating factor of symptoms and mental and physical functioning in individuals with PPS.
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So that's interesting to know.

The discussion section says:
A recent review by Van den Bergh et al. [40] showed that the current studies do not provide convincing evidence for an attentional bias towards actual peripheral somatosensory input in patients with PPS, and that there is growing evidence that suggests a lower correspondence between peripheral somatosensory input and symptom reports than expected.
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It also says that the questionnaire used to measure somatosensory amplification (the somatosensory amplification scale or SSAS) has been criticized.
Aronson et al. proposed that SSAS is rather an index of negative emotionality and general distress [8,44]. Prior studies suggested that the association of somatosensory amplification and somatic symptoms at least partly overlaps with factors such as negative affect and anxiety
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These references might be interesting:

[8] ] K.R. Aronson, L.F. Barrett, K.S. Quigley, Feeling your body or feeling badly: evidence for the limited validity of the somatosensory amplification scale as an index of somatic sensitivity, J. Psychosom. Res. 51 (1) (2001) 387–394

[44] ] K.R. Aronson, L.F. Barrett, K.S. Quigley, Emotional reactivity and the overreport of somatic symptoms: Somatic sensitivity or negative reporting style? J. Psychosom. Res. 60 (5) (2006) 521–530​

So overall there seems to be very little evidence for Barsky's somatosensory amplification theory, doesn't it? Would be interesting if someone could study why these ideas seem to remain popular among researchers and clinicians.
 
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Short Version: Symptoms getting worse are due to you paying attention to them.

I'll pass that onto my friend with end stage bowel cancer, whose symptoms were repeatedly dismissed by doctors until it was too late for effective treatment.

Oh wait, she already died.

Must have been her fault for paying attention to her symptoms. :grumpy:
 
NelliePledge said:
I reckon most people with chronic illnesses literally do the opposite of symptom focussing. Anyone with gradual onset ME will have gone years undiagnosed pushing through symptoms.
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Something that is really easy to show in a formal way. Would actually be great to do that. Not sure it would change anything since BPS beliefs are impervious to evidence but at least it should be done.

But we're kind of stuck in a place where we have so little funds that it would be a waste to do this knowing it would not change anyone's opinion. And yet it is necessary and should have been done a long time ago by the people pushing this tripe but they know it's false and don't care anyway. Because every dollar spent has the opportunity cost of not going to research that could be a breakthrough moment. So the myths just keep on persisting because beliefs supersede evidence.

What an absolute mess.
 
Yes an absolute mess. What sprung to my mind was an occasion when I was focussed on pushing through the flu type symptoms I’d got up and washed dressed set off driving to work and after 1/2 a mile a lightbulb went on that I really wasn’t well enough to be behind the wheel and therefore should not be going to work. This was about 10 years before diagnosis. Also numerous times in the 2-3 years in the run up to diagnosis I secretly dialled in in to morning work teleconferences from bed as I was desperate not to be off sick but just couldn’t function well at that time of day so would try to blag my way through and catch up on actions in the afternoons when I had some energy.
 
Continuing on with what Michiel mentioned, the full quote:

Although in the original theory by Barsky [5] symptom focusing and amplification in response to sensory input is assumed, there is ongoing debate about the actual role of body- and illness related sensory stimuli in PPS. Although studies frequently found an association between selfreported somatosensory amplification and physical symptom reports, the evidence from more objective measures in experimental psychological studies has been much less consistent. A recent review by Van den Bergh et al. [40] showed that the current studies do not provide convincing evidence for an attentional bias towards actual peripheral somatosensory input in patients with PPS, and that there is growing evidence that suggests a lower correspondence between peripheral somatosensory input and symptom reports than expected. A study on the latent structure of somatic symptom distress showed that somatosensory amplification was in particular associated with the general somatic symptom factor, whereas associations with specific symptoms factors (gastrointestinal, fatigue, cardio-pulmonary, and pain symptoms) were small. As such, somatosensory amplification seems to relate specifically to cognitive affective aspects of symptom perception and not to its sensory aspects [41]. A cross-sectional study showed that body awareness was related to somatosensory amplification [42] and the authors suggested that the ‘hypervigilance’ component might be more closely connected to ‘body awareness’ and less to ‘interoceptive accuracy’ than stated in the original description by Barsky [5]. This would put more emphasis on symptom perception instead of attentional bias towards visceral or proprioceptive stimuli as originally postulated.
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In our study we did not measure interoceptive accuracy in response to actual peripheral sensory input, but focused on the symptom perception perspective.
There has been some debate on the construct validity of the somatosensory amplification scale (SSAS). Although the scale intended to measure hypervigilance to mild somatic and visceral sensations and a tendency to interpret them as pathological, Aronson et al. proposed that SSAS is rather an index of negative emotionality and general distress [8,44]
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Mhmm... Which means the "symptom amplification" hypothesis (that attentional bias or hypervigilance actually increases somatosensory signals or "heightened perceived threat and vulnerability") has no basis and it is simply questionnaire answers being correlated with other questionnaire answers.

If they tested functioning objectively, they might have had an acceptable study on their hands, but as published, it is junk.
 
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