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Background: Difficult asthma is a severe subgroup of asthma in which the main feature is uncontrollability of symptoms. Psychopathology is suggested to be prominent in patients with difficult asthma and considered important in its treatment; however, the evidence is scarce., Aims: To describe psychopathology in difficult asthma, both major mental and personality disorders, based on diagnostic interviews., Method: This study was conducted in a specialised asthma care centre. A total of 51 patients with difficult asthma were diagnosed at the start of the treatment programme using two structured clinical interviews for both major mental (SCID-I) and personality disorders (SCID-II) according to DSM-IV-TR., Results: About 55% of the patients with difficult asthma had a psychiatric disorder of which 89% was undiagnosed and untreated before being interviewed. About 49% had a minimum of one major mental disorder of which the cluster of anxiety disorders was the most common cluster of major mental disorders, followed by somatoform disorders. About 20% were diagnosed with a personality disorder. Of the 10 patients with a personality disorder, 9 had an obsessive-compulsive personality disorder., Conclusions: This study demonstrates that more than half of patients with difficult asthma had a psychiatric disorder of which 89% was unrecognised. This study highlights the importance of offering patients with difficult asthma a psychiatric diagnostic interview and/or a psychiatric consultation as part of their routine medical examination and provision of appropriate psychiatric treatment. Moreover, it highlights the urgency of further research into the role of psychopathology in the development of difficult asthma., Declaration of Interest: None., Copyright and Usage: © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Background: Patients with severe somatoform disorder (in secondary and tertiary care) typically experience functional impairment associated with physical symptoms and mental distress. Although psychotherapy is the preferred treatment, its effectiveness remains to be demonstrated., Aims: To examine the effectiveness of psychotherapy for severe somatoform disorder in secondary and tertiary care compared with treatment as usual (TAU) but not waiting-list conditions., Method: Main inclusion criteria were presence of a somatoform disorder according to established diagnostic criteria and receiving psychotherapy for somatoform disorder in secondary and tertiary care. Both randomised and non-randomised trials were included. The evaluated outcome domains were physical symptoms, psychological symptoms (depression, anxiety, anger, general symptoms) and functional impairment (health, life satisfaction, interpersonal problems, maladaptive cognitions and behaviour)., Results: Ten randomised and six non-randomised trials were included, comprising 890 patients receiving psychotherapy and 548 patients receiving TAU. Psychotherapy was more effective than TAU for physical symptoms (d = 0.80 v. d = 0.31, P<0.05) and functional impairment (d = 0.45 v. d = 0.15, P<0.01), but not for psychological symptoms (d = 0.75 v. d = 0.51, P = 0.21). These effects were maintained at follow-up., Conclusions: Overall findings suggest that psychotherapy is effective in severe somatoform disorder. Future randomised controlled studies should examine specific interventions and mechanisms of change.

Background: Our knowledge about medically unexplained symptoms (mus) is increasing, but translating this knowledge into more effective treatment, particularly if symptoms are severe, continues to be problematical., Aim: To clarify the physical aspect of mentalisation (body-mentalisation) and to outline a theoretical perspective of body-mentalisation, starting from theories such as the attachment theory and the mentalisation theory, and to describe the diagnostic and therapeutic value of this approach., Methods: Clinical experience with body-mentalisation led to a systematic literature search (via PsycInfo and Medline)., Results: Body-mentalisation is the ability to detect the signals of our own and of other, to respond to them and perceive the links with underlying mental states. Poor body-mentalisation occurs frequently in patients with severe mus and can be treated successfully by means of intensive residential or day-therapy programmes., Conclusion: Body-mentalisation may turn out to be a useful concept in connection with the treatment of persons with severe mus. More research is needed to test the diagnostic validity and therapeutic relevance of this concept.