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Progress in Neuropsychopharmacology & Biological Psychiatry 78 (2017) 18–26

Contents lists available at ScienceDirect

Progress in Neuropsychopharmacology
& Biological Psychiatry
journal homepage: www.elsevier.com/locate/pnp

Somatization in Parkinson's Disease: A systematic review MARK


a,b,⁎ a b,c d a
Danilo Carrozzino , Per Bech , Chiara Patierno , Marco Onofrj , Bo Mohr Morberg ,
Astrid Thomasd, Laura Bonannid, Mario Fulcherib
a
Psychiatric Research Unit, Psychiatric Centre North Zealand, Copenhagen University Hospital, Hillerød, Denmark
b
Department of Psychological, Health, and Territorial Sciences, University “G. d'Annunzio” of Chieti-Pescara, Chieti, Italy
c
Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
d
Department of Neuroscience and Imaging, University “G. d'Annunzio” of Chieti-Pescara, Chieti, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: The current systematic review study is aimed at critically analyzing from a clinimetric viewpoint the clinical
Clinimetrics consequence of somatization in Parkinson's Disease (PD). By focusing on the International Preferred Reporting
Parkinson's Disease Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive electronic
Psychogenic parkinsonism literature research strategy on ISI Web-of-Science, PsychINFO, PubMed, EBSCO, ScienceDirect, MEDLINE,
Somatization
Scopus, and Google Scholar databases. Out of 2.926 initial records, only a total of 9 studies were identified as
clearly relevant and analyzed in this systematic review. The prevalence of somatization in PD has been found to
range between 7.0% and 66.7%, with somatoform disorders acting as clinical factor significantly contributing to
predict a progressive cognitive impairment. We highlighted that somatization is a highly prevalent comorbidity
affecting PD. However, the clinical consequence of such psychiatric symptom should be further evaluated by
replacing the clinically inadequate diagnostic label of psychogenic parkinsonism with the psychosomatic
concept of persistent somatization as conceived by the Diagnostic Criteria for Psychosomatic Research (DCPR).

1. Introduction focusing on such research studies, a specific diagnostic risk seems to be


prominent in this medical setting. That is, somatization is described as a
Parkinson's Disease (PD) is a progressive neurodegenerative dis- pseudo-clinical condition (e.g., almost a simulation phenomenon as
order consisting of specific motor and non-motor symptoms, including historically reported with the concept of hysteria) only mimicking real
different prominent psychiatric disturbances (McLaughlin et al., 2014). symptoms of a medical disease (Babinski, 1892; Halligan et al., 2001;
However, whereas the main psychiatric comorbidities (e.g., depression, Mangelli et al., 2009; Shorter, 2006). Such diagnostic and therapeutic
anxiety, psychosis and its related clinical symptoms such as visual perspectives are clinically linked to the concept of somatization as
hallucinations and delusions), and the psychological disturbances in PD symptom only originating in the mind, whose clinical manifestations
(e.g., pathological gambling, impulse control disorders, psychological may be considered as imaginary and not as real symptoms (Tavel,
distress, and impaired quality of life) were extensively analyzed by a 2015) deserving appropriate psychosomatic evaluations and treatments
bulk of scientific literature (Aarsland et al., 2007; Brown and Fernie, both by medical doctors (e.g., psychiatrist, neurologist) and clinical
2015; Calandrella and Antonini, 2011; Chang and Fox, 2016; De la Riva psychologists (e.g., psychotherapist) (Fava et al., 2016). Indeed, con-
et al., 2014; Factor et al., 2014; Fénelon et al., 2006; Lauterbach, 2004; ceiving somatization as psychogenic in origin substantially means to
Mack et al., 2012; Marsh et al., 2004; McKinlay et al., 2008; Nuti et al., overemphasize a model of mind-body dualism by pointing out that
2004; Onofrj et al., 2006, 2007, 2013; Voon et al., 2009; Weintraub, everything is just in the mind or medically unexplained (Mangelli et al.,
2009, 2016), to date relatively few studies evaluated somatization 2009; Rief and Martin, 2014). By contrast, a multifactorial definition of
symptoms in PD (Baik, 2012; Benaderette et al., 2006; Bugalho et al., somatization was provided by Lipowski (1986, 1987, 1988) who
2012; Felicio et al., 2010; Gaig et al., 2006; Onofrj et al., 2010, 2011; identified this clinical aspect as a specific individual tendency to
Pareés et al., 2013a, 2013b; Siri et al., 2010). Furthermore, when experience and communicate somatic symptoms in response to psycho-

Abbreviations: PD, Parkinson's Disease; PRISMA, International Preferred Reporting Items for Systematic Reviews and Meta-Analyses; DCPR, the Diagnostic Criteria for Psychosomatic
Research; UKPDSBB, UK Parkinson's Disease Society Brain Bank Criteria; SFMD, Somatoform disorders; DRS-2, Dementia Rating Scale-2; DLB, Dementia with Lewy Bodies; AD, Alzheimer
Disease; MSA, Multiple System Atrophy; PSP, Progressive Supranuclear Palsy; FTD, Frontotemporal Dementia; SSD, Somatic Symptoms and Related Disorders; AIB, Abnormal Illness
Behavior

Corresponding author at: Department of Psychological, Health, and Territorial Sciences, University “G. d'Annunzio” of Chieti-Pescara, Via dei Vestini no. 31, Chieti 66100, Italy.
E-mail address: danilo.carrozzino@unich.it (D. Carrozzino).

http://dx.doi.org/10.1016/j.pnpbp.2017.05.011
Received 12 February 2017; Received in revised form 25 April 2017; Accepted 13 May 2017
Available online 15 May 2017
0278-5846/ © 2017 Elsevier Inc. All rights reserved.
D. Carrozzino et al. Progress in Neuropsychopharmacology & Biological Psychiatry 78 (2017) 18–26

logical distress and to seek medical help for it, by implying that research studies examining psychogenic movement disorders in other
somatization may occur during a physical illness and, in some cases, different neurogical disorders (e.g., movement disorders not clinically
it can also coexist with, mask, and be facilitated by such an illness. linked to PD).
On this theoretical background, we aimed to further underline the The following were additional eligibility criteria: when limiting our
questionable scientific trends that carry on to conceive the diagnosis of population target to patients reporting a medically-based diagnosis of
somatization symptoms by focusing on a misleading organic and PD without any type of restriction as regards the age and gender of
functional dichotomy (Sirri and Fava, 2013). In this regard, we have participants, we have excluded all studies examining somatization in
critically analyzed research studies that have evaluated somatization in other neurological patients (e.g., Alzheimer's disease, Huntington's
PD in order to outline an alternative multidimensional concept of disease, Gilles de la Tourette syndrome, epilepsy, multiple sclerosis).
somatization. Therefore, the general aim of our study is to provide new Furthermore, studies were discarded if they were clearly irrelevant or
research insights on the clinical link between somatization and PD by its full-text was not available.
performing a systematic review of studies that have examined the
relative weight (Kissen, 1963) of somatization syndrome in this
neurological medical setting. Specifically, the two main research 2.2. Information sources and searches
questions we aimed to answer are as follows:
When focusing on the International Preferred Reporting Items for
1. By focusing on the exploratory nature of our systematic review Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati
study, is it clinically valid conceiving somatization not only as a et al., 2009; Moher et al., 2009), a comprehensive electronic literature
mere medical consequence of PD or just a psychogenic alteration but research strategy was carried out by systematically searching on the
as true somatic symptoms arising from multiple etiological factors of following international databases: ISI Web-of-Science, PsychINFO,
both medical and psychological nature (Lipowski, 1986, 1987, PubMed, EBSCO, ScienceDirect, MEDLINE, and Scopus from inception
1988)? of each database to June 2016. In addition, we have performed a
2. When providing a definition of clinimetrics as a clinically based manual search by analyzing the reference lists and citations from all
measurement method combining the micro-analysis of rating scales initially identified articles in order to screen for other potentially
with the experienced clinical judgment of macro-analytic signifi- relevant papers not previously identified by the systematic search. We
cance (Bech, 2012; Tomba and Bech, 2012), what is the main have fulfilled also a further research of the literature on Google Scholar
clinical utility potentially deriving from performing a clinimetric database in order to detect any missed articles potentially relevant.
evaluation of somatization in PD? Concerning the search strategy on which we have focused on when
screening the research-literature for titles, abstracts, and topics, the
2. Methods various combination of terms, acting as keywords, was the following:
“somatization” OR (i.e., used as Boolean operator) “somatisation”,
2.1. Eligibility criteria “somatoform disorders” OR “somatic symptom and related disorders”,
“medically unexplained symptoms” OR “MUS”, “functional symptoms”
Eligible articles included English-language papers published in peer- OR “psychogenic symptoms”, “psychosomatic factors” OR “psychologi-
reviewed journals, only reporting original data (i.e., brief research cal factors”, “psychiatric symptoms” OR “non-motor symptoms”, “neu-
report, short communication, research letter, original research article, ropsychiatric symptoms” OR “non-organic symptoms”, “hypochondria-
case report or single case, clinical study, meta-analysis, as well as other sis” OR “hypochondria”, “hysteria” OR “conversion disorder” as search
type of papers comprising quantitative data) on the study of somatiza- terms combined, using the Boolean “AND” operator, with words as
tion in neurological patients having a medically documented diagnosis “Parkinson's Disease” OR “parkinsonism”, “parkinsonian” OR “neurol-
of PD, as clinically evaluated by an expert neurologist according to the ogy patients”.
International UK Parkinson's Disease Society Brain Bank Criteria Concerning the data extraction method that we have carried out,
(UKPDSBB) (Hughes et al., 1992). A further inclusion criterion for titles and abstracts were initially extracted and screened by one of
included original articles was that studies had to specifically evaluate authors (D.C.). Subsequently, papers appearing potentially relevant
somatization in PD by clinically and/or statistically analyzing its main were retrieved and two reviewers (D.C. and M.O.) independently
features. That is, we have focused on research studies encompassing a evaluated each of the full text reports, arriving at a consensus regarding
clinical or a psychometric definition of the somatization concept. eligibility. When assessing the validity of the eligible studies, three
Concerning the clinical definition, we have focused on the Lipowski's reviewers (D.C., M.O., and M.F.) independently rated each research
(1986, 1987, 1988) viewpoint of the somatization concept to critically report by carefully focusing on eligibility criteria. Any types of
reanalyze the potential clinical consequence of somatization in PD. disagreements were resolved by a final consensus among these primary
With regard to the psychometric evaluation of somatization symptoms, reviewers (D.C., M.O., and M.F.) and the senior investigator (P.B.).
we have included research studies focusing on the SCL-90-R somatiza- Furthermore, regarding each excluded study, six reviewers (D.C., M.O.,
tion subscale reflecting, according to Derogatis (1983, 1994), the C.P., A.T., B.M.M., and L.B.) determined which elements of the
specific amount of psychological distress arising from the individual electronic research literature were not addressed. Finally, in case of
perceptions of bodily dysfunction. By contrast, studies lacking a specific missing information within selected studies, we have contacted the
measure of somatization or exclusively dealing with somatization in PD corresponding author to recover missing details.
only from a theoretical point of view (i.e., avoiding any type of clinical
or quantitative evaluation), such as commentaries, letters to the editor,
books or book chapters, reviews or systematic reviews, conference 2.3. Analysis and data synthesis
abstracts or conference posters were not included.
Furthermore, because of the frequent use of psychogenic term as When statistically taking into account the significant heterogeneity
synonym of somatization in PD, as well as by taking into account the of experimental study designs (i.e., cross-sectional, observational, single
evidence that many patients having psychogenic movement disorders case or longitudinal/follow-up studies), as well as the different defini-
meet the diagnostic criteria (i.e., according to the DSM-IV-TR) for a tions and measurement methods used to evaluate somatization, a meta-
somatoform disorder (American Psychiatric Association, 2000; Ferrara analysis was not deemed to be fully appropriate. On this background,
et al., 2011), we have also included relevant studies analyzing we provided a qualitative synthesis of relevant results by performing a
psychogenic parkinsonism in PD. By contrast, we have excluded all systematic review of the literature.

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D. Carrozzino et al. Progress in Neuropsychopharmacology & Biological Psychiatry 78 (2017) 18–26

0.53) reaching a pathological level in the 66.7% of the total sample


IDENTIFICATION

Records identified through


databases and manual searching of early stage PD patients. That is, they (Bugalho et al., 2012) showed
(n = 2.926) that, out of 36 PD patients constituting the total sample, 24 participants
reported pathological levels of somatization symptoms. Such significant
scores were followed by obsessive-compulsive (52.8% of the patients),
Records after duplicates removed
depression (36.1% of the patients) and anxiety symptoms with a
(n = 973)
prevalence of 27% of patients (Bugalho et al., 2012).
Similarly, a previous study of Siri et al. (2010) found a high
SCREENING

Records excluded
prevalence of somatization symptoms among PD patients with frequen-
Records screened for evaluation according to eligibility
(n = 973) criteria cies reaching a pathological level in the 56% of the total PD sample.
(n = 883) That is, the authors (Siri et al., 2010) were able to show that
somatization symptoms were reported by nearly half of the PD patients.
Additional records When reporting the mean scores and the standard deviation values on
ELIGIBILITY

excluded for the the SCL-90-R somatization subscale (1.16 ± 0.65), Siri et al. (2010)
Full-text articles assessed for following reasons:
eligibility established a cut-off score for evaluating the severity of individual
Not pertinent with
(n = 90) review aims (n = 57) frequencies reported by patients as follows: a score of > 1 was
Non-English research considered as a mild pathological symptom, whereas a score > 2
articles (n = 9) was evaluated as a severe clinical condition. In this regard, they (Siri
Full-text not available
(n = 15)
et al., 2010) demonstrated that somatization occurred as a mild
symptom in 56.0% of the patients and as a severe clinical condition
INCLUDED

Studies included for analysis


in 11% of the patients.
in the systematic review
(n = 9)
3.3. Somatoform disorders (SFMD) and PD

Fig. 1. PRISMA flowchart of the systematic search.


When focusing on a large cohort of 1360 newly diagnosed neuro-
logical patients, including a total of 412 participants with a medical
3. Results diagnosis of PD or genetic parkinsonism, Onofrj et al. (2010) reported,
at the time of primary neurologic diagnosis, a prevalence of somato-
3.1. Selection of articles form disorders in 29 PD patients, i.e. 7.0% of their PD sample. The first
diagnosis of SFMD based on direct observation of symptoms was
The search of ISI Web-of-Science, PsychINFO, PubMed, EBSCO, followed by a second evaluation performed with a semi-structured
ScienceDirect, MEDLINE, and Scopus databases, including both the interview according to the DM-IV-TR criteria (American Psychiatric
manual search on reference lists and the additional electronic search on Association, 2000). When considering that follow-up data were avail-
Google Scholar database, provided a total of 2.926 citations, as briefly able only for 22 of 29 PD patients, recurrent somatoform disorders were
described in the PRISMA flow chart (see Fig. 1) showing the diagram of longitudinally confirmed in the 1–2 years on 20 of 22 PD patients and
the research literature. further documented in the 2–4 years follow-up in 18 of 22 PD patients
When adjusting for duplicates by using web programs for managing (Onofrj et al., 2010). The mean number of SFMD recurrences during the
bibliographical references (i.e., Mendeley and EndNote), 973 studies 4-year follow-up was 3.4 ± 1.6 among patients with PD. Such SFMD
remained. Subsequently, by reviewing titles and abstracts in order to condition in PD presented with different clinical manifestations,
exclude papers which clearly did not meet the eligibility criteria, 883 including motor, sensory, or pain symptoms (Onofrj et al., 2010).
studies were further discarded. The remaining 90 full-text articles were Furthermore, when comparing PD patients obtaining a DSM-IV-TR
evaluated for potential eligibility. Out of 90 articles, 57 studies were diagnosis of SFMD to PD patients without SFMD, PD patients diagnosed
excluded because they were not pertinent with the aims of our with SFMD scored significantly higher (32.2 ± 3.8) on the SCL-90-R
systematic review, other 9 were discarded as non-English articles, and somatization subscale than other PD patients (22.3 ± 8.0) without
15 additional studies (of which 14 classified also as clearly irrelevant) SFMD (p < 0.05) with no other statistically significant differences on
were excluded because the full-text was not available also after the other SCL-90-R subscales (Onofrj et al., 2010). Finally, by perform-
contacting by email the corresponding authors. The aforementioned ing a regression analysis, the authors (Onofrj et al., 2010) found that
81 studies were also excluded because they focused on the evaluation of the scores reported by PD patients with SFMD on the Mini Mental State
somatization symptoms in other medical settings not examining the Examination and on the Dementia Rating Scale-2 (DRS-2) showed a
potential clinical relevance of somatization in patients with PD. progressive cognitive decline statistically different from PD patients
Finally, a total of 9 research studies were identified as clearly without SFMD. After controlling for age and education, PD patients
relevant and selected for inclusion in this systematic review, as briefly with SFMD, as compared to PD patients without SFMD, reported a
illustrated in the Table 1. The included studies were summarized and significantly lower reduction in DRS-2 score over time (Onofrj et al.,
critically analyzed according to the aims of the current systematic 2010).
review. When summarizing the selected research studies, we divided In line with the aforementioned findings operating as preliminary
results according to the following specific chapters: a) somatization and results (Onofrj et al., 2010), Onofrj et al. (2011) performed a new
PD; b) somatoform disorders and PD; c) psychogenic parkinsonism. No research report acting as an updated version of their previous original
unpublished relevant research studies were obtained and reported. study (Onofrj et al., 2010). By focusing on a clinical population of 1572
newly diagnosed patients, including 488 with a medically documented
3.2. Somatization and PD diagnosis of PD, the authors (Onofrj et al., 2011) have showed that the
frequency of SFMD was significantly higher in both Dementia with
When screening for psychiatric symptoms by focusing on scores on Lewy Bodies (DLB) (n = 29 patients, 19%) and PD patients (n = 37
the nine SCL-90-R subscales, whose pathological levels were calculated patients, 7.5%) than in patients affected from other neurodegenerative
by fixing a cut-off of > 1, a research study from Bugalho et al. (2012) disorders (i.e., Alzheimer Disease – AD, Multiple System Atrophy –
revealed that somatization was the most prevalent dimension with MSA, Progressive Supranuclear Palsy – PSP, Frontotemporal Dementia
significant scores (mean and standard deviation values = 1.32 ± – FTD). Similarly to the previous original research study (Onofrj et al.,

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D. Carrozzino et al.

Table 1
Selected research studies evaluating somatization's factor in PD.

Study reference Aims Study design Sample Main results Measure of SOM

Baik (2012) Critically analyzing psychogenic movement disorders in one Single case Single case: 65-year-old woman One PD patient reporting psychogenic Clinically established by a neurologist
PD patient with a diagnosis of PD movement disorders improved with internal
attention
Benaderette et al. To assess to what extent the combination of independent Follow-up Study 9 patients (4 women and 5 men) Out of the 9 patients initially referred with a Evaluated as PsyP according to Fahn and
(2006) clinical, electrophysiological, and [123I]-FP-CIT SPECT Scan with a diagnosis of suspected PsyP diagnosis of PsyP, 6 were reclassified with a Williams criteria for inconsistent or
evaluations potentially improves diagnostic accuracy of PsyP Mean age (SD): 49.9 (NA) years form of combined PsyP and PD incongruent movements
Bugalho et al. Screening a population of early stage PD patients for Cross-sectional 36 early stage PD patients, as 66.7% of the total sample reported Evaluated by using both SCL-90-R and BPRS
(2012) psychiatric symptoms, including SOM study diagnosed according to UKPDSBB pathological levels of somatization
Mean age (SD): 72.8 (7.01) years symptoms
Felicio et al. Evaluating PsyP in order to assess the potential presence of an Follow-up study 5 consecutive patients with a All patients initially diagnosed as having Evaluated as PsyP according to Fahn and
(2010) underlying degenerative parkinsonism diagnosis of early-onset only a PsyP developed also an early-onset PD Williams criteria for inconsistent or
parkinsonism according to incongruent movements
UKPDSBB
Mean age (SD): 37.4 (3.4) years
Gaig et al. (2006) To test whether patients with parkinsonism have a suspected Follow-up study 9 patients (5 women and 4 men) Out of the 9 patients with suspected PsyP, Evaluated as PsyP according to Fahn and

21
psychogenic origin with suspected PsyP, of which 7 one patient obtained also a diagnosis of PD Williams criteria for inconsistent or
with a diagnosis of PD incongruent movements
Mean age (SD): 53.7 (NA) years
Onofrj et al. To evaluate prevalence, impact and clinical phenomenology of Prospective A total of 1360 patients, of which 7.0% of PD patients presented with SFMD Assessed by following evaluations: 1. Direct
(2010) SFMD in PD study 412 with a medical diagnosis of PD clinical observation; 2. DSM-IV-TR based
according to UKPDSBB semi-structured interview; 3. SCL-90-R SOM
Mean age (SD): 63.9 (12.5) years Subscale
Onofrj et al. Fully clarifying the clinical relevance of SFMD in parkinsonism Prospective A total of 1572 patients, of which The frequency of SFMD in PD patients was Evaluated by following polimodal methods: 1.
(2011) study 488 were diagnosed as having PD 7.5% clinical observation; 2. DSM-IV-TR based
Mean age (SD) of PD patients: 64.5 semi-structured interview; 3. SCL-90-R SOM
(13.4) years subscale
Pareés et al. To examine the clinical relevance of SOM in PD Single cases 11 patients with a diagnosis of PD All the 11 patients with a UKPDSBB Clinically established by a neurologist
(2013a) according to UKPDSBB diagnosis of PD developed a clinically
Mean age (SD): 55 (11) years established or documented functional
movement disorders
Siri et al. (2010) Investigating the prevalence of psychiatric symptoms, Cross-sectional A total of 486 PD outpatients The prevalence of somatization symptoms in Evaluated by using SCL-90-R self-rating-scale
including SOM in PD study Mean age (SD): 65.82 (10.25) years PD was 56.0%

Abbreviations throughout the table. BPRS = brief psychiatric rating scale; NA = not available; PD = Parkinson's Disease; PsyP = psychogenic parkinsonism; SCL-90-R = symptom-check-list-90-revised; SD = standard deviation;
SFMD = somatoform disorders; SOM = somatization; UKPDSBB = International UK Parkinson's Disease Society Brain Bank Criteria.
Progress in Neuropsychopharmacology & Biological Psychiatry 78 (2017) 18–26
D. Carrozzino et al. Progress in Neuropsychopharmacology & Biological Psychiatry 78 (2017) 18–26

2010) as concerning the SFMD rate of recurrence, Onofrj et al. (2011) parkinsonism, a research study by Gaig et al. (2006) revealed an
were able to show that the SFMD episodes were recurrent in all PD underlying neurodegenerative parkinsonism (i.e., nigrostriatal degen-
patients previously diagnosed with SFMD, reporting a mean (SD) eration) in 1 patient. Such finding was considered an indirect evidence
recurrence rate over the follow-up period of 2.0 (1.0). Concerning the of the psychogenic parkinsonism disorder co-occurring in PD (Gaig
prevalent complaints arising during the direct clinical observation, the et al., 2006). In addition to the aforementioned 9 patients with
following were the recurrent themes reported by PD patients with suspected psychogenic parkinsonism, the authors (Gaig et al., 2006)
SFMD: 1. Denial of PD diagnosis followed by responding to the evaluated also two other patients for screening for the potential
dopaminergic therapy with marked side effects, including nausea and comorbidity between psychogenic parkinsonism and PD. The first
other clinical symptoms (e.g., intolerable gastric pain, burping and patient was a 45-year-old man previously diagnosed with PD and
retching, confusion, sensation of empty head, dizziness with normal suspected of psychogenic parkinsonism because during the 5 years of
orthostatic blood pressure, hypersomnolence or insomnia); 2. A specific treatment, his mild PD did not significantly progress (Gaig et al., 2006).
history of hypochondriac beliefs consisting of prominent concerns Such PD patient developed also anxiety, depression, and multiple
about their disease (Onofrj et al., 2011). somatic complaints, including dizziness, lower back and leg pain, as
well as generalized weakness (Gaig et al., 2006). The second patient
3.4. Psychogenic parkinsonism was a 56-year-old having a medical diagnosis of PD (Gaig et al., 2006).
Psychogenic parkinsonism was suspected also in this case because the
When evaluating 11 outpatients fulfilling the UKPDSBB criteria for PD patient not only complained of dizziness, swallowing and memory
PD (Hughes et al., 1992), a relatively recent research report from Pareés difficulties but also her tremor presented with variable frequency and
et al. (2013a) found that all patients under examination developed amplitude and decreased with distraction (Gaig et al., 2006). Similarly,
clinically established and documented functional symptoms before the a study of Benaderette et al. (2006), originally aimed at evaluating the
diagnosis of PD (i.e., 4 patients with a mean latency of 2.5 years and a concordance between independent clinical, electrophysiological, and
standard deviation of ± 1 year) or during the course of the neurological [123I]-FP-CIT SPECT scan explorations for examining a sample of 9
disease (i.e., the remaining 7 PD patients). The authors reported also patients with a suspected diagnosis of psychogenic parkinsonism,
that their PD patients have showed incongruent, variable, distractible, showed that 6 patients obtained a new diagnosis of combined PD and
entrainable symptoms with tremor as the most common clinical sign psychogenic parkinsonism. The authors (Benaderette et al., 2006)
followed by gait disorder and fixed dystonia (Pareés et al., 2013a). The found that all the neurological patients with PD showed also functional
authors have also focused on two illustrative cases to further demon- symptoms. In other terms they showed that none of the examined
strate the clinically significant overlay between PD organic disorders patients presenting with pure PD without psychogenic symptoms
and functional symptoms (Pareés et al., 2013a). The first clinical (Benaderette et al., 2006).
exemplification was a 69-year-old PD patient diagnosed with functional
tremor associated to PD by presenting a combination of typical 4. Discussion
parkinsonian rest tremor in the left hand and a medically unexplained
severe postural tremor (Pareés et al., 2013a). Such severe postural When focusing on research studies analyzed in our systematic
tremor was distractible, entrainable, and stopped briefly with ballistic review, we have found a prominent concept of somatization conceived
movements of the opposite hand (Pareés et al., 2013a). The second as psychogenic disorder operating as independent clinical aspect from
clinical exemplification was a 55-year-old PD patient diagnosed with PD medical symptoms. However, dealing with somatization in PD
tremor and bradykinesia combined with a clinically significant func- means identifying this complex clinical factor as a psychosomatic
tional symptomatology consisting of unusual reactions to single doses symptom whose onset is clinically linked to both psychic and somatic
and short courses of a number of drugs, including both L-dopa and components of a medical disease. That is, when focusing on a
nondopaminergic drugs (Pareés et al., 2013a). The unusual reaction psychometric evaluation of somatization without assuming any clinical
reported by this PD patient comprised dramatic worsening of the link with PD medical symptoms or by performing a clinical observation
tremor combined with shortness of breath, sweating and an unpleasant of somatoform or psychogenic disorders, the authors (Baik, 2012;
individual psychological feeling (Pareés et al., 2013a). Benaderette et al., 2006; Bugalho et al., 2012; Felicio et al., 2010;
Another study, reporting the co-morbid presence of underlying Gaig et al., 2006; Onofrj et al., 2010, 2011; Pareés et al., 2013a, 2013b;
functional psychogenic movement disorders during PD, was fulfilled Siri et al., 2010) have conducted an assessment of somatization in PD
by Baik (2012) who focused on a single case to demonstrate the according to the scientifically questionable and clinically misleading
relevance of attention for improving gait disorder in one PD patient. concept of medically unexplained symptoms (Cosci and Fava, 2015).
That is, Baik (2012) found that when a 65-year-old PD patient On this background, in order to provide an answer to our first research
concentrated hard on her gait or when she touched her hand to the question, we aimed to replace the inadequate concept of somatization
posterior of her neck, her dragged and slow gait improved significantly. as no more than a medical consequence of PD-related complications
Baik (2012) showed also that the abnormal gait of the PD patient due to nigrostriatal dopamine loss or as a psychogenic problem missing
improved when the examiner touched his hand to her neck. That is, the an organic explanation with an etiological model assuming a wide
patient's symptoms fluctuated and she had an underlying psychiatric range of medical and psychological elements acting as predisposing,
comorbidity, including anxiety and depression (Baik, 2012). Similarly, precipitating and maintaining factors affecting somatization in PD
a study from Felicio et al. (2010) showed that all patients, initially (Lipowski, 1986, 1987, 1988). In this regard, it is clinically valid
diagnosed as having only a psychogenic movement disorder, later assuming somatization in PD as a true somatic symptom arising from a
developed also an early-onset parkinsonism. Specifically, Felicio et al. multifactorial causation consisting of several medical and psychological
(2010) found that all patients originally presenting with a psychogenic factors. This research hypothesis is in line with Barsky et al. (1986) who
parkinsonism developed early-onset parkinsonism with a mean age conceived such somatic symptoms as a final common pathway through
(years-old) at first evaluation of 37.4 ± 3.7 and a mean disease which emotional problems, psychiatric disturbances, and organic
duration (years) of 4.3 ± 1.8. All the patients with psychogenic pathology all express themselves. Also Mechanic and Volkart (1960)
parkinsonism who underwent a neuropsychiatric evaluation fulfilled introduced a specific unifying factor underlying somatization symptoms
the DSM-IV diagnostic criteria for a conversion disorder (Felicio et al., and encompassing all the aforementioned multiple variables. They have
2010). indeed focused on the original concept of illness experience in order to
Similarly, by using striatal dopamine transporter (DAT) imaging in point out the potential clinical link connecting somatization to the
9 patients (i.e., 5 women and 4 men) with suspected psychogenic varying patterns of individuals to perceive, to evaluate and to respond

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D. Carrozzino et al. Progress in Neuropsychopharmacology & Biological Psychiatry 78 (2017) 18–26

to their bodily sensations and symptoms. Such illness behavior may act measuring somatization symptoms (Carrozzino et al., 2016a, 2016b).
as a core clinical factor predisposing PD patients to an increased risk to As showed in our two previous research studies (Carrozzino et al.,
develop somatization symptoms during their chronic and neurodegen- 2016a, 2016b), whereas the somatization subscale of Kellner (1987)
erative disease. consists of a list of somatic symptoms not reaching an acceptable level
However, although the potential clinical relevance of these clinical of scalability as valid measure of somatization, the somatization
aspects in PD, we have found a paucity of studies specifically focused on subscale of Derogatis (1983, 1994) obtained a sufficient level of
screening for somatization in PD, because this psychiatric symptom has scalability including items truly reflecting the underlying somatization
been considered a controversial issue (Onofrj et al., 2010, 2011; Pareés dimension under examination. Indeed, while the somatic subscale from
et al., 2013a, 2013b) constituting an apparent contradiction mainly the Symptom Questionnaire as argued also by Kellner (1987) cannot be
linked to the tendency to neglect the clinical relevance of a psycholo- regarded as evidence of somatization and must be interpreted with
gical factor in the presence of an organic disease (Cosci and Fava, caution in the presence of a physical disease, the SCL-90-R somatization
2015). subscale consists of a clinimetrically valid screening measure reflecting,
Nevertheless, the few studies analyzing somatization in PD revealed according to Derogatis (1983, 1994), the amount of psychological
a clinically very high incidence of somatization in PD with frequencies distress arising from the individual perceptions of bodily dysfunctions
ranging from 7.0% to 66.7% (Bugalho et al., 2012; Onofrj et al., 2010, (Carrozzino et al., 2016a, 2016b). The potential clinical utility of the
2011; Siri et al., 2010). A similar result has been reported by evaluating SCL-90-R somatization subscale was previously outlined also by
somatization as psychogenic movement disorder with frequencies Bernstein et al. (1994) in a sample of patients with low-back pain.
ranging from 10% to 15% among neurological patients showing an Specifically, the authors (Bernstein et al., 1994) showed that the SCL-
underlying organic movement disorder as well (Baik and Lee, 2012). 90-R somatization subscale had sufficient specific variance because this
However, the observed wide variation of the somatization prevalence scale not simply measures a physical discomfort or a general psycho-
rates in PD ranging from 7% to 67% actually demonstrates a largely logical distress but the specific amount of distress clinically related to
uncertain data probably linked to several confounding factors operating the subjective perceptions of bodily dysfunctions. This is a further
in the examined studies. For instance, the following methodological evidence of the clinical validity of the SCL-90-R somatization subscale
aspects should be taken into account in order to identify potential truly measuring the somatization construct in line, from a clinimetric
confounding factors: a) the different disease duration and clinical point of view, with the concept of somatization as introduced by
staging of PD patients under examination; b) the heterogeneity of study Lipowski (1986, 1987, 1988). Such SCL-90-R somatization subscale
design; c) the several and different measures used by authors to combined with the DCPR diagnostic system may provide a clinically
evaluate somatization according to psychometric instruments (i.e., comprehensive psychosomatic assessment of somatization symptoms in
mainly by use of self-rating scales) or by exclusively focusing on clinical PD. On this basis, when providing an answer to our second specific
observation. research question, clinimetrics acts as a clinically based measurement
Clinimetrics may further provide a suitable solution in this regard as method aimed at evaluating to what extent it is valid joining the use of
a specific diagnostic approach to analyze the clinical consequence of self-rating scales as sufficient statistic in terms of level of scalability as
somatization symptoms in PD by combining the experienced clinical assessed by item analysis (Mokken, 1971; Rasch, 1980) with the clinical
judgment as a test of clinical validity with the item response theory judgment (Emmelkamp, 2004; Fava et al., 2015) in order to identify the
models in order to evaluate to what extent it is statistically and core symptoms of a clinical condition by differentiating co-morbid
clinically valid to sum the individual items of a scale as a total score disturbances from primary clinical diagnosis (Bech, 2012). Specifically,
constituting a sufficient statistics (Bech, 2012) for detecting somatiza- clinimetrics may provide significant diagnostic advantages by identify-
tion. That is, clinimetrics may constitute a significant methodological ing the chronological relationship between PD medical features and the
approach for remodelling the psychosomatic assessment by linking the onset of somatization symptoms. In this regard, the clinimetric
initial evaluation of the patient by the use of a semistructured clinical approach provides also a diagnostic solution for joining hard and soft
interview with a micro-analytic examination of symptoms as assessed data (Tomba and Bech, 2012) in order to carry out a comprehensive
with clinically valid self-rating scales (Bech, 2012; Tomba and Bech, evaluation of a medical disease and its comorbidities, including
2012). Concerning a clinimetrically valid semistructured clinical inter- somatization (Bech, 2012; Fava et al., 2004, 2016). Therefore, the
view for the assessment of somatization symptoms in several medical potential main advantages arising from a clinimetric analysis comprise
settings (Porcelli and Guidi, 2015), including patients with neurode- a more accurate assessment of somatization symptoms and a better
generative disorders, the Diagnostic Criteria for Psychosomatic Re- evaluation and monitoring of its potential consequences on therapeutic
search - DCPR (Fava et al., 1995, 2016; Sirri and Fava, 2013) may offer outcomes (Carrozzino et al., 2016b).
a clinically significant contribution as screening measure for the initial On this background, to the very best of our knowledge, the current
assessment of the somatization symptoms in PD. That is, the DCPR study is the first systematic review aimed at critically analyzing,
clinimetric system consists of a clinically valid instrument translating according to a clinimetric viewpoint (Bech, 2012; Carrozzino et al.,
specific psychosocial variables derived from a bulk of research studies 2016a, 2016b; Fava and Belaise, 2005; Fava et al., 2012; Feinstein,
into operational tools (Fava et al., 2016). The clinical utility of the 1982, 1983, 1987; Tomba and Bech, 2012), somatization in PD by
diagnostic structured interview based on the DCPR system was recently focusing on the concept of psychosomatic syndrome (i.e., persistent
further evidenced by Porcelli and Guidi (2015), as well as it was somatization) as originally conceived by the DCPR (Fava et al., 1995,
recently released the revised version of such diagnostic criteria (Fava 2016; Sirri and Fava, 2013). Thus, by providing a clinically suitable
et al., 2016). Thus, the DCPR clinimetric system may allow to detect definition of somatization as frequent co-existing ailment in diverse
more adequately the clinical relevance of somatization in PD by medical settings, whose likelihood to arise is significantly increased by
identifying its subthreshold symptomatology frequently co-occurred the presence of a somatic chronic disease (Härter et al., 2007), we have
in patients with medical disorders that have known organic cause also highlighted that somatization in PD has a documented prognostic
(Porcelli and Guidi, 2015). As completing part of the clinimetric relevance based on the evidence that this psychological factor signifi-
assessment that we are proposing, such initial clinical evaluation should cantly contributes to predict the development of dementia similar to
be further validated by using specific self-rating scales aimed at cognitive decline of DLB (Onofrj et al., 2010). With regard to this
identifying the somatic symptoms underlying the psychological distress clinically important evidence, identifying somatization in PD poten-
expressed and communicated in the form of somatization symptoma- tially means contributing to predict PD medical outcomes, namely the
tology. In this regard, it was recently evaluated from a clinimetric point future risk of a cognitive impairment. In this regard, the key question
of view the clinical validity of specific self-rating scales aimed at for the clinicians (e.g., neurologist, clinical psychologist or psychiatrist)

23
D. Carrozzino et al. Progress in Neuropsychopharmacology & Biological Psychiatry 78 (2017) 18–26

should change by moving from the previously clinically inconsistent this regard, the DCPR, differently from the DSM categories neglecting
evaluation of considering whether a deterioration or the treatment- the operational translation of AIB into diagnostic criteria, provides a
refractory symptoms in patients with PD could represent the develop- clinimetrically useful alternative trans-diagnostic model for evaluating
ment of a functional disorder rather than a disease progression (Pareés the psychosomatic link between AIB and the onset of somatization
et al., 2013a, 2013b) to a new clinically adequate clinimetric re- symptoms (Cosci and Fava, 2015; Porcelli and Guidi, 2015).
analysis aimed at testing the relative contribution (Kissen, 1963) of
somatization in the prediction of the disease progression (Guidi et al., 5. Conclusion
2013). In other terms, a clinically comprehensive assessment in PD
should include also a clinimetric assessment in order to measure the Researchers and clinicians interested in understanding the phenom-
relative weight (Kissen, 1963) of somatization as symptom potentially enology and impact of somatization symptoms in PD should definitively
affecting the neurodegenerative course of PD (Onofrj et al., 2010). dismiss the clinically inadequate concept of somatization as diagnosis
Concerning the main clinical interpretation of somatization symp- of exclusion by re-evaluating this psychosomatic syndrome as a highly
toms in PD, Stacy et al. (2010) conceived the somatization comorbidity prevalent and distinct additional clinical condition frequently occurring
as a symptom of the increased general sensitivity of PD patients to the in PD during the neurodegenerative course of this disease. Moreover,
fluctuations of their motor and non-motor symptoms (Kellner, 1994) when taking into consideration the significant association between
occurring during wearing off phenomenon. In line with this hypothesis, somatization and a reduced psychological well-being and quality of life
an emerging model (Edwards et al., 2012) provided a comprehensive (Croicu et al., 2014; Fava et al., 2016) which operates in turn as
description of somatization as a hierarchical neurobiologically protective factors in a number of medical disorders (Pressman and
mediated symptom arising from a complex combination of body Cohen, 2005; Ryff, 2014), detecting and treating somatization in PD
focused attention, individual expectations, physical and emotional potentially means to contribute promoting a positive mental health
experiences and beliefs about illness. These findings are also in line condition (Bech et al., 2016; Croicu et al., 2014; Fava and Bech, 2016).
with the concept of somatosensory amplification as introduced by Such clinimetrically based psychosomatic viewpoint should imply, in
Barsky and Wyshak (1990) who showed that the tendency to experience terms of clinical practice, an integration of psychological care within
a somatic sensation as intense, noxious, and disturbing leads to focus the standard medical treatment by addressing specific psychotherapeu-
the attention on physical signs by significantly increasing awareness of tic interventions. For instance, the emerging Well-Being Therapy (Fava,
bodily changes and perception of bodily sensations finally resulting in 2016) consists of a clinically valid psychotherapeutic treatment for
somatization symptoms (Barsky et al., 1990; Marcus et al., 2007). promoting a biopsychosocial expression of health as absence of
symptoms and simultaneous attainment of a positive mental state
4.1. Main methodological limitations of existing research studies (Bech et al., 2016; Engel, 1960, 1982; Fava and Bech, 2016).
Finally, concerning the main future research perspective, the DCPR
Before providing a specific recommendation for future research diagnostic systems (Fava et al., 1995; Porcelli and Guidi, 2015; Porcelli
studies, we have to underline the primary limitations of the original and Rafanelli, 2010; Wise, 2009) combined with the Derogatis SCL-90-
reports that we have included in the current systematic review. R somatization subscale (Carrozzino et al., 2016b) are strongly
Concerning the limitations of sample enrollment, none of the recommended as screening methods to clinimetrically detect the
selected studies specifically included a control group from a general clinical burden of the somatization symptoms in PD.
population in order to perform a comparison between PD clinical
participants and healthy respondents. Conflict of interest
Another limitation consists of the prevalent diagnostic method used
by authors (Onofrj et al., 2010, 2011) in the evaluation of somatization All authors have no potential conflict of interests to disclose. All
according to the Diagnostic and Statistical Manual of Mental Disorders, authors equally contributed in the preparation and writing of this
Text Revision, DSM-IV-TR (American Psychiatric Association, 2000). manuscript.
This shortcoming is mainly related to the clinically obsolete diagnostic
label of somatoform disorder diagnostically acting as synonym of Acknowledgments
medically unexplained symptoms (Cosci and Fava, 2015; Sirri et al.,
2013). In this regard, despite the new DSM-5 classification system None.
acknowledges the potential occurrence of somatization in established
medical disorders (American Psychiatric Association, 2013), its impro- References
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