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Psychological flexibility in somatic symptom and related disorders: A case control study.
Selker, René J D M, Koppert, Tim Y, Houtveen, Jan H et al. · Journal of psychiatric research · 2024 · DOI
Quick Summary
This study looked at how well people can handle difficult thoughts and feelings without being overwhelmed by them—a skill called psychological flexibility. Researchers compared 154 people with somatic symptom disorder (SSD, where people are very distressed by physical symptoms) to nearly 2,000 people with other conditions like ME/CFS or no illness. People with SSD had much lower psychological flexibility than both other groups, and this lower flexibility was linked to worse mental health.
Why It Matters
ME/CFS researchers have long noted that ME/CFS differs from conditions like SSD by lacking the excessive psychological preoccupation with symptoms as a diagnostic criterion. This study demonstrates that psychological flexibility—the ability to coexist with symptoms without catastrophic thinking—is indeed more impaired in SSD than in ME/CFS and other CSS, supporting the distinction between these conditions and potentially guiding treatment approaches tailored to each.
Observed Findings
SSD patients had the lowest mean psychological flexibility, followed by CSS patients, with controls having the highest (F=154.5, p<0.001).
74% of SSD patients had low psychological flexibility compared to 42% of CSS patients and 21% of controls.
In SSD, higher psychological flexibility was associated with better mental health (β=0.56, p<0.001).
The protective effect of psychological flexibility diminished at higher levels of somatic symptom severity (interaction β≤0.08, p≥0.10).
Inferred Conclusions
Psychological flexibility is significantly impaired in SSD relative to both CSS and the general population.
Psychological flexibility is associated with mental health outcomes in SSD, but may not compensate for severe somatic symptoms.
Psychological flexibility should be considered as a screening, monitoring, and therapeutic target in SSD management.
Remaining Questions
Does low psychological flexibility in SSD reflect a primary psychological difference, or is it secondary to the distress caused by somatic symptoms?
Would interventions targeting psychological flexibility (such as acceptance and commitment therapy) improve mental health or functional outcomes in SSD populations?
What This Study Does Not Prove
This study does not prove that low psychological flexibility causes worse mental health in SSD—only that they are associated. It also does not show whether improving psychological flexibility would actually improve health outcomes in people with severe somatic symptoms, as the interaction analysis suggested flexibility may not buffer against worsening with symptom severity. The study does not directly investigate ME/CFS-specific mechanisms or whether psychological interventions would be effective.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
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