State and Trait Loneliness In Patients With Somatic Symptom Disorder

The Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV)
described somatoform disorders as a mental illness that is characterized by
physical complaints for which no somatic cause has been found. These complaints
are not imagined and are not imitated or simulated. Previous research has shown
that this group of patients is quite prevalent in healthcare: in primary
healthcare one in three somatic symptoms are medically unexplained, and in
secondary healthcare these numbers are even higher (Khan, Khan, Harezlak, Tu, &
Kroenke, 2003; Kroenke, 2003; Nimnuan, Hotopf, & Wessely, 2001). Patients who
experience medically unexplained somatic symptoms tend to persist in searching
for an explanation or treatment of their symptoms by visiting different medical
doctors. This group of patients thereby causes an expensive burden on health
care resources. The medical and social costs are approximately 7000 euro per
patient a year (Zonneveld,
Sprangers, Kooiman, Van *t Spijker, & Busschbach, 2013).

Since the publication of the Diagnostic and Statistical Manual of Mental
Disorders 5th Edition (DSM-5) in 2013, the classification of somatoform
disorders has changed. The classification of somatoform disorders in DSM-IV is
controversial. There is no consistent statement about dealing with comorbidity.
Also the use of the criterion for unexplained somatic symptoms, raises a lot of
questions. As a result, the somatoform disorders as classified by the DSM-IV
have been, only partly, replaced in the DSM-V by somatic symptom and related
disorders. Contrary to the somatoform disorders of DSM-IV, in which one or more
somatic symptoms have to be unexplained, symptoms can either be medically
explained or unexplained to set the diagnosis of a somatic symptom disorder
(SSD) (Van der Feltz* Cornelis, & Van Houdenhove, 2014). Most relevant are the
maladaptive responses these patients have when confronted with their somatic
symptoms. As described in DSM-V this might involve excessive thoughts, emotions
and behavior coherent with the somatic symptoms. Another criterion is the
persistence of somatic symptoms, typically more than six months. At this moment
little is known about the prevalence and costs of SSD, and therefore we will
rely on the literature on somatoform disorders as classified by the DSM-IV. In
addition to implications and consequences, also causal and sustaining factors
of SSD are currently unknown.

People with somatoform disorders often feel misunderstood and socially
rejected. They also experience loneliness. Research has found that the number
of chronic illnesses can be a predictor of loneliness (Van Dam, 2012;
Dirkzwager, & Verhaak, 2007; Kara, & Mirici, 2004; Kool, Middendorp, Boeije, &
Geenen, 2009; Theeke, 2009). Loneliness can be defined as an unpleasant feeling
when experiencing a discrepancy between the desired and the actual social
network of a person (Perlman, & Peplau, 1981). The quantity or the quality of
one*s social relationships are not conform to someone*s needs (Hawkey, &
Cacioppo, 2010; Van Roekel, 2014). Loneliness tends to be a large problem in
current society. In The Netherlands there is a high prevalence of loneliness.
In total 43% of the adult population (19 years and older) indicates to be
lonely, based on a questionnaire filled in by 457.153 Dutch citizens
(Gezondheidsmonitor Volwassenen GGD-en, CBS en RIVM, 2016).

There are clear links between loneliness, social support and health. Whereas
social support has been associated with better health, loneliness has been
associated with poorer health. Additionally, social support can minimize
loneliness (Segrin, & Domschke, 2011; Segrin, & Passalacqua, 2010). The Social
Support Theory of Cohen (1985) explains the relation between social support and
well-being. First, being part of a social network provides positive experiences
and stable, socially rewarding roles. Second, a social network enables
resources to respond to the needs of a person during stressful events. Research
has shown that loneliness is related to several medical issues. Social
epidemiology has shown that, among others, the absence of positive social
relationships is a significant risk factor for broad-based morbidity and
mortality. People who feel lonely have a greater probability to develop heart
diseases in comparison to people who feel socially connected. Loneliness has
also found to be a risk factor for the development of pain, depression, and
fatigue, which are common symptoms in SSD (Cacioppo, & Cacioppo, 2014; Jaremka
et al., 2014; Jaremka, Fagundes, Glaser, Bennett, Malarkey, & Kiecolt-Glaser,
2013; Mushtag, Shoib, Shah, & Mushtag, 2014; Stadler, Snyder, Horn, Shrout, &
Bolger, 2012) .

In most studies examining the negative health effects of loneliness, loneliness
was measured as a trait (Hawkey, &*Cacioppo, 2010).*In the last years, research
has started to shift focus to measuring variability and fluctuations in
feelings of loneliness, also referred to as state levels of loneliness. In many
of these studies, fluctuations have been investigated using Experience Sampling
Method (ESM). ESM is a procedure to assess participants in their daily
environment, providing repeated moment-to-moment measurements. The most
interesting aspect of ESM is that it relies on an app instead of paper diaries
(Myin-Germeys, Oorschot, Collip, Lataster, Delespaul, & van Os, 2009). ESM has
several advantages compared to questionnaires or diaries. First, ecological
validity is higher, because measurement can take place during participant*s
normal daily life environment. Second, it minimizes recall bias, because
participants evaluate their experiences in the moment. By using paper diaries
it is more difficult to measure at several moments of the day and these diaries
are often filled in at the end of the day which increases a recall bias. This
is an important limitation in the current population as research has shown that
people who suffer from somatic complaints tend to overestimate symptoms as time
passes by (Houtveen, & Oei, 2006). Finally, using ESM allows measurement and
investigation of possible influences of the context people are in (Brown,
Strauman, Barrantes-Vidal, Silvia, & Kwapil, 2011). Studies on state levels of
loneliness in the daily life of adolescents, have shown that loneliness is
affected by temporal characteristics and social contexts (Doane, & Adam, 2010;
Van Roekel, 2014). Measuring in daily life provides insights into moment to
moment effects (Roekel, Scholte, Engels, Goossens, & Verhagen, 2014). For
example, in depression, moment to moment differences in loneliness have been
investigated by using ESM, elucidating the causal mechanisms of depression. The
results have shown that state loneliness was followed by an increase of
negative evaluations of social company and being more alone. Trait loneliness
predicted symptoms of depression (van Winkel, Wichers, Collip, Jacobs, Derom,
Thiery, Myin-Germeys, & Peeters, 2017).

Based on the above described overview, the question arises which role the
experience of loneliness in daily life can play in developing and maintaining
somatic symptoms and maladaptive responses as typically seen in somatic symptom
disorder. Until now, research cannot make solid conclusions on the causal
relationship between loneliness and somatic symptoms. On the one hand somatic
symptoms and chronic illness can function as risk factors for loneliness. On
the other hand loneliness itself can act as a risk factor for several somatic
symptoms. Knowledge about the relation between loneliness and somatic symptom
disorder may help in the development of more tailored interventions in this
group of patients.

The current research will consist of two phases, each representing one study.
In the first phase possible differences in trait loneliness and evaluation of
social support between patients with SSD and healthy controls will be
investigated using standardized questionnaires. Assuming that patients with SSD
will report more loneliness, the second study will investigate the role of
loneliness in a more detailed way by fluctuations of loneliness during the day,
also referred to as the state levels of loneliness, using ESM. More
specifically, the relation between fluctuations in loneliness and fluctuations
in the experience of somatic symptoms will be examined. One of the most
powerful characteristics of ESM research is that it can provide insights not
only in the relation between variables, but also in the causal direction of
that relation. The current study will investigate the direction of the relation
between loneliness and somatic symptoms.

Phase 1
In a between group design, patients with SSD and healthy controls will be
compared concerning their average level of loneliness (i.e. trait loneliness)
and their evaluation of the current social support they experience.

Phase 2
An observational design using the Experience Sampling Method (ESM) will be used
to measure loneliness and somatic symptoms at multiple moments in daily lives
of the participants. Individuals will be asked to fill in the same questions on
different, quasi-random (random beeps with fixed intervals) time points during
the day. A *beep* on their smartphone signals to answer the questions directly
or at least within 10 minutes.

There are no risks or adverse consequences associated with participation in the
study. Participants can stop their participation at any time.